Provider Demographics
NPI:1003827601
Name:FULLER, JEFFERY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
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 1:1501 KINGS HWY
Mailing Address - Street 2:MANAGED CARE
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103
Mailing Address - Country:US
Mailing Address - Phone:318-675-7737
Mailing Address - Fax:318-675-5666
Practice Address - Street 1:4864 JACKSON ST
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICAL SERVICES
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-6400
Practice Address - Country:US
Practice Address - Phone:318-675-7737
Practice Address - Fax:318-675-5666
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018474207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1357723Medicaid
LAC67403Medicare UPIN
LA51120F600Medicare ID - Type Unspecified