Provider Demographics
NPI:1003816364
Name:FULLER, JOHN ALAN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALAN
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 W MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-2018
Mailing Address - Country:US
Mailing Address - Phone:405-752-9600
Mailing Address - Fax:405-752-9650
Practice Address - Street 1:5101 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-2018
Practice Address - Country:US
Practice Address - Phone:405-752-9600
Practice Address - Fax:405-752-9605
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14299207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100824640BMedicaid
OKD39119Medicare UPIN