Provider Demographics
NPI:1285651893
Name:FULLER, SAMUEL PRIOLEAU (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:PRIOLEAU
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1330 OAK LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-2513
Mailing Address - Country:US
Mailing Address - Phone:434-384-0610
Mailing Address - Fax:434-384-1074
Practice Address - Street 1:1330 OAK LN
Practice Address - Street 2:SUITE 100
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503-2513
Practice Address - Country:US
Practice Address - Phone:434-384-0610
Practice Address - Fax:434-384-1074
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
VA0101031832208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB09788Medicare UPIN