Provider Demographics
NPI:1497774749
Name:FULLER, PAUL G JR (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:G
Last Name:FULLER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:90 PRESIDENTIAL PLZ
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-2240
Mailing Address - Country:US
Mailing Address - Phone:315-464-4357
Mailing Address - Fax:315-464-2030
Practice Address - Street 1:90 PRESIDENTIAL PLZ
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2240
Practice Address - Country:US
Practice Address - Phone:315-464-4357
Practice Address - Fax:315-464-2030
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-09-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY122518208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00382150Medicaid
NYJ400002211Medicare PIN