Provider Demographics
NPI:1386651628
Name:FULLER, ROBERT R (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
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:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1204 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-1923
Practice Address - Country:US
Practice Address - Phone:434-924-2500
Practice Address - Fax:434-244-9487
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101242146207VM0101X, 207VM0101X
VT042-0010703207V00000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROU PTAN
NY02532236OtherMY MEDICAID
VT1010433Medicaid
VAC06778OtherGROU PTAN