Basic Information
| Provider Information | |||||||||
| NPI: | 1730368374 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FULLERTON PULMONARY & CRITICAL CARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7630 | ||||||||
| Address2: | |||||||||
| City: | LAGUNA NIGUEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926077630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496433345 | ||||||||
| FaxNumber: | 9496433560 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 ALTA VISTA DR | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928354027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148711507 | ||||||||
| FaxNumber: | 9496433560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2007 | ||||||||
| LastUpdateDate: | 10/31/2007 | ||||||||
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| AuthorizedOfficialLastName: | BOUGAS | ||||||||
| AuthorizedOfficialFirstName: | PANAGIOTIS | ||||||||
| AuthorizedOfficialMiddleName: | PLATO | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7148711507 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | G84424 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | G84424 | 01 | STATE LICENSE NUMBER | OTHER | 00G844240 | 05 | CA | MEDICAID |