Provider Demographics
NPI:1194036210
Name:FULLER, ERIC BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:BRADLEY
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVE
Mailing Address - Street 2:BOX 69
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-6190
Mailing Address - Fax:
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:BOX 69
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-6190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-058032207X00000X
CA137416207XP3100X
IL036.132558207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery