Provider Demographics
NPI:1073836250
Name:FULLER, RAYMOND EVERETT (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:EVERETT
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:15 ANDRE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-3010
Mailing Address - Country:US
Mailing Address - Phone:616-475-8446
Mailing Address - Fax:616-475-1272
Practice Address - Street 1:15 ANDRE ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-3010
Practice Address - Country:US
Practice Address - Phone:616-475-8446
Practice Address - Fax:616-475-1272
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301023680207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease