=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497824262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSAN L FULLEMANN MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2006
-----------------------------------------------------
Last Update Date | 08/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1820 OGDEN DR 1ST FLOOR
-----------------------------------------------------
City | BURLINGAME
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94010-5384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-697-7202
-----------------------------------------------------
Fax | 650-697-7059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1820 OGDEN DR 1ST FLOOR
-----------------------------------------------------
City | BURLINGAME
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94010-5384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-697-7202
-----------------------------------------------------
Fax | 650-697-7059
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. SUSAN L FULLEMANN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 650-697-7202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | G51875
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------