Provider Demographics
NPI:1053667758
Name:FULLER, JAY (OD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 E PASS RD STE A
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3864
Mailing Address - Country:US
Mailing Address - Phone:228-262-0266
Mailing Address - Fax:
Practice Address - Street 1:2170 E PASS RD STE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3864
Practice Address - Country:US
Practice Address - Phone:228-262-0266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS851152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist