Provider Demographics
NPI:1427540178
Name:FULLER, BRIAN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:DO
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 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:5649 WYNNEWOOD DR STE 104
Practice Address - Street 2:
Practice Address - City:LAURYS STATION
Practice Address - State:PA
Practice Address - Zip Code:18059-1124
Practice Address - Country:US
Practice Address - Phone:610-262-6641
Practice Address - Fax:610-262-0428
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS021622208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics