1477851764 NPI number — DAVID B. FULLER, D.O., P.C.

Table of content: (NPI 1477851764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477851764 NPI number — DAVID B. FULLER, D.O., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID B. FULLER, D.O., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1477851764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2004 MEDICAL CENTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAY MINETTE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36507-4163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-937-7910
Provider Business Mailing Address Fax Number:
251-937-1846

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2004 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAY MINETTE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36507-4163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-937-7910
Provider Business Practice Location Address Fax Number:
251-937-1846
Provider Enumeration Date:
03/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
FULLER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
251-937-7910

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  DO495 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 080174991 . This is a "PALMETTO GBA - RAILROAD MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51077277 . This is a "BLUECROSS/BLUESHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 0005495200 . This is a "AETNA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000077277 . This is a "MEDICARE ID" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000077277 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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