Provider Demographics
NPI:1326276577
Name:FULLER, MOLLY LYNN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:LYNN
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5335 ROBINHOOD VILLAGE DR # 178
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-9820
Mailing Address - Country:US
Mailing Address - Phone:336-448-3060
Mailing Address - Fax:336-998-3333
Practice Address - Street 1:122 E KINDERTON WAY
Practice Address - Street 2:
Practice Address - City:BERMUDA RUN
Practice Address - State:NC
Practice Address - Zip Code:27006-7303
Practice Address - Country:US
Practice Address - Phone:336-448-3060
Practice Address - Fax:336-998-3333
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01115207W00000X, 207WX0200X, 207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCENROLLEDMedicaid
MNENROLLEDMedicaid
IAENROLLEDMedicaid
NCENROLLEDMedicaid
MNH400115747Medicare PIN