1568463487 NPI number — DR. BRADLEY DEAN FULLERTON M.D.

Table of content: DR. BRADLEY DEAN FULLERTON M.D. (NPI 1568463487)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568463487 NPI number — DR. BRADLEY DEAN FULLERTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLERTON
Provider First Name:
BRADLEY
Provider Middle Name:
DEAN
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:
1568463487
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/22/2006
NPI Reactivation Date:
04/06/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2714 BEE CAVES RD STE 106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78746-5672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-347-7246
Provider Business Mailing Address Fax Number:
512-347-7245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2714 BEE CAVES RD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78746-5677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-347-7246
Provider Business Practice Location Address Fax Number:
512-347-7245
Provider Enumeration Date:
08/02/2005

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: 208100000X , with the licence number:  K3731 , 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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