Provider Demographics
NPI:1417470147
Name:FULLER, MARK A
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:FULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 W WILLOW KNOLLS DR APT 503A
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1446
Mailing Address - Country:US
Mailing Address - Phone:217-330-0928
Mailing Address - Fax:
Practice Address - Street 1:2215 W WILLOW KNOLLS DRIVE
Practice Address - Street 2:APT 503A
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1446
Practice Address - Country:US
Practice Address - Phone:217-330-0928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL82-2237856Medicaid