Provider Demographics
NPI:1437119302
Name:FULLER, STANLEY BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:BRIAN
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-277-4075
Mailing Address - Fax:336-277-4095
Practice Address - Street 1:2825 LYNDHURST AVE
Practice Address - Street 2:STE 101
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4146
Practice Address - Country:US
Practice Address - Phone:336-277-4075
Practice Address - Fax:336-277-4095
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34605208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437119302Medicaid
NC34605OtherNC LLICENSE
NC8934129Medicaid
NC8934129Medicaid
NC34605OtherNC LLICENSE
VA1437119302Medicaid
NC2164443CMedicare ID - Type Unspecified