Provider Demographics
NPI:1134296163
Name:FULLER, ROGER R JR (DC)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:R
Last Name:FULLER
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 W BOSTON
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-7874
Mailing Address - Country:US
Mailing Address - Phone:480-963-4473
Mailing Address - Fax:480-963-4513
Practice Address - Street 1:128 W BOSTON
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-7874
Practice Address - Country:US
Practice Address - Phone:480-963-4473
Practice Address - Fax:480-963-4513
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3831111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0944910OtherBCBSAZ
P00112110OtherUN HEALTHCARE RAILROAD RE
P00112110OtherUN HEALTHCARE RAILROAD RE