=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952720104
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY RICHARD FULLAM M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2014
-----------------------------------------------------
Last Update Date | 02/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 W THOMAS RD # 400
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85013-4407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-406-6262
-----------------------------------------------------
Fax | 602-406-6261
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 W THOMAS RD STE 301
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85013-4407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-406-6262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0008X
-----------------------------------------------------
Taxonomy Name | Neuromuscular Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number | T1068
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | T1068
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 28833
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084N0008X
-----------------------------------------------------
Taxonomy Name | Neuromuscular Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number | 73815
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------