1669560579 NPI number — DR. B.D. FULLER & ASSOC

Table of content: (NPI 1669560579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669560579 NPI number — DR. B.D. FULLER & ASSOC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. B.D. FULLER & ASSOC
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:
1669560579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3602 LUMINOSO LN W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROUND ROCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78681-2395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-636-1995
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11200 LAKELINE MALL DR LOWR LEVEL
Provider Second Line Business Practice Location Address:
STE E-5
Provider Business Practice Location Address City Name:
CEDAR PARK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78613-1501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-401-6000
Provider Business Practice Location Address Fax Number:
512-401-6004
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FULLER
Authorized Official First Name:
BRIDGETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
512-636-1995

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  6991TG , 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)

  • Identifier: 1528025582 . This is a "NPI ENUMERATOR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com