Provider Demographics
NPI:1306841002
Name:FULLER, RICHARD E (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
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 1:17780 VERSAILLES CT
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5026
Mailing Address - Country:US
Mailing Address - Phone:262-389-1375
Mailing Address - Fax:
Practice Address - Street 1:17780 VERSAILLES CT
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5026
Practice Address - Country:US
Practice Address - Phone:262-389-1375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32988-020207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI208000000XMedicaid
WI31875900Medicaid
WI1306841002OtherBCBS
WI009600205Medicare PIN
WI084834217Medicare ID - Type Unspecified