Provider Demographics
NPI:1275503724
Name:FULLER, VALERIE W (DO)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:W
Last Name:FULLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:VALERIE
Other - Middle Name:
Other - Last Name:WITMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:55 MERZ BLVD.
Mailing Address - Street 2:STE A
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333
Mailing Address - Country:US
Mailing Address - Phone:330-864-9000
Mailing Address - Fax:330-864-9004
Practice Address - Street 1:55 MERZ BLVD.
Practice Address - Street 2:STE A
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333
Practice Address - Country:US
Practice Address - Phone:330-864-9000
Practice Address - Fax:330-864-9004
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-008780207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2801221Medicaid
OH2801221Medicaid
OHI37851Medicare UPIN
OHVA9363051Medicare PIN