MEDICARE: DR. CATHERINE G FULLER 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	207K00000X	Allergy & Immunology Physician	A43782	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	WA43782F	OTHER	CA	PTAN

General Provider Information

NPI Number	:	1851349120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CATHERINE G FULLER M.D.

Provider Business Mailing Address
First Line	:	11645 WILSHIRE BLVD
Second Line	:	SUITE 1150
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1708
Country	:	US
Telephone Number	:	310-828-7978
Fax Number	:	310-909-1911

Provider Business Practice Location Address
First Line	:	11645 WILSHIRE BLVD
Second Line	:	SUITE 1150
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1708
Country	:	US
Telephone Number	:	310-828-7978
Fax Number	:	310-909-1911

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

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	07/08/2010

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