Provider Demographics
NPI:1093730749
Name:FULLER, SAMUEL EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:EDWARD
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10800 E GEDDES AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-3895
Mailing Address - Country:US
Mailing Address - Phone:303-761-9190
Mailing Address - Fax:720-874-4462
Practice Address - Street 1:1801 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5154
Practice Address - Country:US
Practice Address - Phone:303-761-9190
Practice Address - Fax:720-874-4462
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA728912085R0202X
WY7318A2085R0202X
NE232772085R0202X
KS04-416472085R0202X
HIMD198732085R0202X
CO434662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA3249113OtherMEDICARE
KS111257122OtherMEDICARE
CO650671OtherMEDICARE
CO88153746Medicaid
NENA1214128OtherMEDICARE PTAN
CO638284YQ33OtherMEDICARE
CO638284YQN9OtherMEDICARE
CO638284YQPGOtherMEDICARE
NENA1215129OtherMEDICARE PTAN
CO638284AE6YOtherMEDICARE
NENA2517106OtherMEDICARE PTAN
CO638284ZLJ3OtherMEDICARE PTAN