Provider Demographics
NPI:1396034658
Name:FULLER, STANLEY R (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:R
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 MINNIE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3006
Mailing Address - Country:US
Mailing Address - Phone:907-456-7760
Mailing Address - Fax:907-328-1867
Practice Address - Street 1:116 MINNIE ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3006
Practice Address - Country:US
Practice Address - Phone:907-456-7760
Practice Address - Fax:907-328-1867
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AK100664207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program