Provider Demographics
NPI:1356743207
Name:ELITE SPORTS PODIATRY, PA
Entity type:Organization
Organization Name:ELITE SPORTS PODIATRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:FULLEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-241-2582
Mailing Address - Street 1:1700 N MCMULLEN BOOTH RD STE C2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-2129
Mailing Address - Country:US
Mailing Address - Phone:727-330-7646
Mailing Address - Fax:727-330-7645
Practice Address - Street 1:1700 N MCMULLEN BOOTH RD
Practice Address - Street 2:SUITE C-2
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-2130
Practice Address - Country:US
Practice Address - Phone:727-330-7646
Practice Address - Fax:727-330-4645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-23
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3445213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU19859Medicare UPIN