1548359979 NPI number — DAVID A FULLER MD

Table of content: DAVID A FULLER MD (NPI 1548359979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548359979 NPI number — DAVID A FULLER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLER
Provider First Name:
DAVID
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548359979
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 COOPER PLZ
Provider Second Line Business Mailing Address:
SUITE 408
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08103-1438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-968-7363
Provider Business Mailing Address Fax Number:
856-968-8288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 COOPER PLZ
Provider Second Line Business Practice Location Address:
SUITE 408
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08103-1438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-968-7363
Provider Business Practice Location Address Fax Number:
856-968-8288
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  MA67224 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XS0106X , with the licence number: MA67224 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1165178 . This is a "HEALTHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3K5443 . This is a "HEALTHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 01707828 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2884943 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 01000344701 . This is a "AMERICHOICES" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7700202 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P2697348 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1000025140 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 36089 . This is a "UNIVERSITY HEALTH PLAN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1318485 . This is a "PA BS HIGHMARK" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2011301000 . This is a "AMERIHEALTH/KEYSTONE/IBC/PA BS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1114872002 . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2260119 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 60007696 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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