Provider Demographics
NPI:1902984438
Name:FULLMER, JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:FULLMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:26901 BEAUMONT BLVD
Mailing Address - Street 2:SUITE 3D
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1861
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:248-898-9060
Practice Address - Fax:248-898-9054
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY271175207ZN0500X, 207ZP0101X
WI54513 - 020207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology