Provider Demographics
NPI:1730368374
Name:FULLERTON PULMONARY & CRITICAL CARE INC
Entity type:Organization
Organization Name:FULLERTON PULMONARY & CRITICAL CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PANAGIOTIS
Authorized Official - Middle Name:PLATO
Authorized Official - Last Name:BOUGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-871-1507
Mailing Address - Street 1:PO BOX 7630
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92607-7630
Mailing Address - Country:US
Mailing Address - Phone:949-643-3345
Mailing Address - Fax:949-643-3560
Practice Address - Street 1:1100 ALTA VISTA DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4027
Practice Address - Country:US
Practice Address - Phone:714-871-1507
Practice Address - Fax:949-643-3560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84424207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G84424OtherSTATE LICENSE NUMBER
CA00G844240Medicaid
CA00G844240Medicaid