Active NPI
Connor Michael Fullerton, MD
- Student in an Organized Health Care Education/Training Program
- Gainesville, FL
National Provider Identifier
1114667698
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Student in an Organized Health Care Education/Training Program
- Practice address
- 1600 SW Archer Rd
Gainesville, FL 32610-3003 - Phone
- (352) 265-0076
- NPI assigned
- Mar 31, 2022
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | Primary |
Addresses
Primary practice location
1600 SW Archer Rd
Gainesville, FL 32610-3003
Mailing address
2501 S Roosevelt Cir
Sioux Falls, SD 57106-3231
Phone (605) 323-9639
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in SD
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20220721001564 | SD | Order and Referring Only - Diagnostic Radiology | 3971984907 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0678 | SD | MD | Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1648684800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1685577600000",
"number": "1114667698",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2501 S ROOSEVELT CIR",
"city": "SIOUX FALLS",
"state": "SD",
"postal_code": "571063231",
"telephone_number": "605-323-9639"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1600 SW ARCHER RD",
"city": "GAINESVILLE",
"state": "FL",
"postal_code": "326103003",
"telephone_number": "352-265-0076"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FULLERTON",
"first_name": "CONNOR",
"middle_name": "MICHAEL",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2022-03-31",
"last_updated": "2023-06-01",
"certification_date": "2023-06-01",
"status": "A"
},
"taxonomies": [
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Gainesville, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 1, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.