Provider Demographics
NPI:1396834412
Name:FULLER, BRIAN G (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:G
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 1:1775 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2125
Mailing Address - Country:US
Mailing Address - Phone:541-269-8520
Mailing Address - Fax:541-267-5083
Practice Address - Street 1:1775 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2125
Practice Address - Country:US
Practice Address - Phone:541-269-8520
Practice Address - Fax:541-267-5083
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO494322085R0001X
ORMD1862912085R0001X
NMMD2023-03622085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA104665Medicare PIN
F49828Medicare UPIN