Provider Demographics
NPI:1154656338
Name:FULLWOOD, DERRICK CORNELIUS
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:CORNELIUS
Last Name:FULLWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4337 LAKE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-3469
Mailing Address - Country:US
Mailing Address - Phone:919-673-6332
Mailing Address - Fax:
Practice Address - Street 1:4442 BONNETSVILLE RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-1001
Practice Address - Country:US
Practice Address - Phone:919-673-6332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health