Provider Demographics
NPI:1477851764
Name:DAVID B. FULLER, D.O., P.C.
Entity Type:Organization
Organization Name:DAVID B. FULLER, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:251-937-7910
Mailing Address - Street 1:2004 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BAY MINETTE
Mailing Address - State:AL
Mailing Address - Zip Code:36507-4163
Mailing Address - Country:US
Mailing Address - Phone:251-937-7910
Mailing Address - Fax:251-937-1846
Practice Address - Street 1:2004 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BAY MINETTE
Practice Address - State:AL
Practice Address - Zip Code:36507-4163
Practice Address - Country:US
Practice Address - Phone:251-937-7910
Practice Address - Fax:251-937-1846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO495207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL080174991OtherPALMETTO GBA - RAILROAD MEDICARE
AL51077277OtherBLUECROSS/BLUESHIELD
AL0005495200OtherAETNA
AL000077277OtherMEDICARE ID
AL000077277Medicaid
AL0005495200OtherAETNA