Provider Demographics
NPI:1376537506
Name:FULLER, RICHARD L (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:FULLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3545 LINCOLN WAY E
Mailing Address - Street 2:SUITE A
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-8624
Mailing Address - Country:US
Mailing Address - Phone:330-837-5191
Mailing Address - Fax:330-837-0755
Practice Address - Street 1:3545 LINCOLN WAY E
Practice Address - Street 2:SUITE A
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-8624
Practice Address - Country:US
Practice Address - Phone:330-837-5191
Practice Address - Fax:330-837-0755
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34. 001836207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0199459Medicaid
OH180019148OtherRAILROAD MEDICARE
OH180019148OtherRAILROAD MEDICARE
OH0439750002Medicare NSC
OH0373751Medicare PIN
A74061Medicare UPIN