Provider Demographics
NPI:1225053366
Name:FULLER, MARIAN ROBERTA-BENTLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIAN
Middle Name:ROBERTA-BENTLEY
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIAN
Other - Middle Name:ROBERTA
Other - Last Name:BENTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1293 E PARKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-8904
Mailing Address - Country:US
Mailing Address - Phone:231-398-1550
Mailing Address - Fax:231-398-9268
Practice Address - Street 1:1293 E PARKDALE AVE
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660
Practice Address - Country:US
Practice Address - Phone:231-398-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079496207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1605115302OtherBLUE CARE NETWORK
MI700E110080OtherGROUP BCBS
MIMF079496OtherSTATE LICENSE
MI1605115302OtherBCBS
MIE16002100Medicare PIN
MII58910Medicare UPIN
MIMF079496OtherSTATE LICENSE