MEDICARE: DR. DAVID LEE FULLER II 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	207R00000X	Internal Medicine Physician	A162126	CA
2	208000000X	Pediatrics Physician	A162126	CA
3	207RI0200X	Infectious Disease Physician	A162126	CA

General Provider Information

NPI Number	:	1962898692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID LEE FULLER II M.D.

Provider Business Mailing Address
First Line	:	3217 OVERLAND AVE APT 7120
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-4529
Country	:	US
Telephone Number	:	419-346-3583
Fax Number	:

Provider Business Practice Location Address
First Line	:	11833 WILMINGTON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90059-3015
Country	:	US
Telephone Number	:	323-318-0442
Fax Number	:

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

Provider Enumeration Date	:	04/09/2015
Last Update Date	:	06/07/2022

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