Individual
DR. JONATHAN ELLIS FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
13616 CALIFORNIA ST, STE 100, OMAHA, NE 68154-5335
(402) 496-0404
(402) 496-0517
Mailing address
13616 CALIFORNIA ST, STE 100, OMAHA, NE 68154-5335
(402) 496-0404
(402) 496-0517
Taxonomy
Speciality
Code
Description
License number
State
207XS0117X
Orthopaedic Surgery of the Spine Physician
Primary
20813
NE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0511642
—
IA
01
—
07113
BCBS
NE
01
—
200031840
RAILROAD MEDICARE
NE
05
—
47081304012
—
NE
Enumeration date
05/31/2005
Last updated
01/28/2009
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