MEDICARE: KISTI POPE FULLER MD

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	207VM0101X	Maternal & Fetal Medicine Physician	24641	NV
2	207VM0101X	Maternal & Fetal Medicine Physician	48767	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	24641	OTHER	NV	STATE LICENSE

General Provider Information

NPI Number	:	1912165713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KISTI POPE FULLER MD

Provider Business Mailing Address
First Line	:	4343 N SCOTTSDALE RD STE 150
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85251-3351
Country	:	US
Telephone Number	:	480-866-8787
Fax Number	:	480-863-9770

Provider Business Practice Location Address
First Line	:	1840 S STAPLEY DR STE 131
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85204-6683
Country	:	US
Telephone Number	:	480-866-8787
Fax Number	:	480-863-9770

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

Provider Enumeration Date	:	05/28/2008
Last Update Date	:	04/02/2024

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Directions to “ KISTI POPE FULLER MD” Practice Location

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