Provider Demographics
NPI:1346234457
Name:FULLER, ERIC ARTHUR (DPM)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:ARTHUR
Last Name:FULLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 ORDWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-2515
Mailing Address - Country:US
Mailing Address - Phone:510-527-1119
Mailing Address - Fax:510-524-9406
Practice Address - Street 1:1178 SAN PABLO AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94706-2245
Practice Address - Country:US
Practice Address - Phone:510-526-1335
Practice Address - Fax:510-526-4419
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3543213E00000X, 213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABBB80382BOtherEDI SUBMITTER NUMBER
CABBB80382BOtherEDI SUBMITTER NUMBER
CA000E35430Medicare ID - Type UnspecifiedMEDICARE NUMBER