Provider Demographics
NPI:1447243589
Name:FULLER, LAWRENCE P (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:P
Last Name:FULLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-5265
Mailing Address - Country:US
Mailing Address - Phone:407-846-2020
Mailing Address - Fax:407-846-8039
Practice Address - Street 1:703 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5265
Practice Address - Country:US
Practice Address - Phone:407-846-2020
Practice Address - Fax:407-846-8039
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC00797152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL596166473OtherTAX ID
FL596166473OtherTAX ID
FLT83915Medicare UPIN
FL20148Medicare ID - Type Unspecified