Provider Demographics
NPI:1356325237
Name:FULLERTON, RANDY CURTIS (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:CURTIS
Last Name:FULLERTON
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 1:9235 COXBORO CT
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7435
Mailing Address - Country:US
Mailing Address - Phone:615-661-5283
Mailing Address - Fax:
Practice Address - Street 1:2021 CHURCH ST
Practice Address - Street 2:SUITE 504
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2021
Practice Address - Country:US
Practice Address - Phone:615-284-7900
Practice Address - Fax:615-284-3488
Is Sole Proprietor?:No
Enumeration Date:2005-12-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16963207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN105694Medicaid
B59030Medicare UPIN
3031620Medicare ID - Type Unspecified