Provider Demographics
NPI:1457454548
Name:FULLER, EDWARD P (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:P
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 1189
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-1189
Mailing Address - Country:US
Mailing Address - Phone:928-854-5370
Mailing Address - Fax:928-854-7942
Practice Address - Street 1:101 CIVIC CENTER LANE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-453-3102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26880207ZP0102X
CAC50618207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ523242Medicaid
AZ523242Medicaid
H04697Medicare UPIN
AZ74673Medicare ID - Type Unspecified