Provider Demographics
NPI:1235336967
Name:FULLER, JOSEPH EDWARD (DC)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:EDWARD
Last Name:FULLER
Suffix:
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 1:1600 MAYFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2009
Mailing Address - Country:US
Mailing Address - Phone:321-439-9080
Mailing Address - Fax:407-599-0692
Practice Address - Street 1:501 N ORLANDO AVE STE 151
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2997
Practice Address - Country:US
Practice Address - Phone:407-599-5555
Practice Address - Fax:407-599-0692
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3550111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT55907Medicare UPIN