MEDICARE: COLE MARIE FULWIDER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	G37354	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G37354A	OTHER	CA	PTAN

General Provider Information

NPI Number	:	1033188560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLE MARIE FULWIDER M.D.

Provider Business Mailing Address
First Line	:	3772 KATELLA AVE.
Second Line	:	SUITE 206
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-6428
Country	:	US
Telephone Number	:	562-430-4294
Fax Number	:	562-493-3573

Provider Business Practice Location Address
First Line	:	3772 KATELLA AVE.
Second Line	:	SUITE 206
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-6428
Country	:	US
Telephone Number	:	562-430-4294
Fax Number	:	562-493-3573

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	06/18/2010

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