1356347306 NPI number — DR. GREGORY MICHAEL FULLER M.D.

Table of content: DR. GREGORY MICHAEL FULLER M.D. (NPI 1356347306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356347306 NPI number — DR. GREGORY MICHAEL FULLER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLER
Provider First Name:
GREGORY
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1356347306
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4351 BOOTH CALLOWAY RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
NORTH RICHLAND HILLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76180-7378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-284-1165
Provider Business Mailing Address Fax Number:
817-284-4990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 NORTH RUFE SNOW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KELLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-431-3800
Provider Business Practice Location Address Fax Number:
817-337-0784
Provider Enumeration Date:
06/23/2005

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: 207Q00000X , with the licence number:  H8646 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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