Provider Demographics
NPI:1407276769
Name:FULLER, DANLIN JENNY (MD)
Entity Type:Individual
Prefix:DR
First Name:DANLIN
Middle Name:JENNY
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 S TELEPHONE RD
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2937
Mailing Address - Country:US
Mailing Address - Phone:405-733-4545
Mailing Address - Fax:405-733-2758
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT206038207R00000X
OK37806207W00000X
GA7482207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine