Basic Information
| Provider Information | |||||||||
| NPI: | 1124205398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLERTON | ||||||||
| FirstName: | SEAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 BRADHURST AVE STE 3100N | ||||||||
| Address2: | |||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105322140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149099018 | ||||||||
| FaxNumber: | 9149099028 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 BRADHURST AVE STE 1900S | ||||||||
| Address2: | |||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105322140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9143471900 | ||||||||
| FaxNumber: | 9143471957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2008 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 247439 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.