Provider Demographics
NPI:1508145871
Name:CHARLES W. FULLER, MD
Entity Type:Organization
Organization Name:CHARLES W. FULLER, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:325-675-0338
Mailing Address - Street 1:1933 PINE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-2431
Mailing Address - Country:US
Mailing Address - Phone:325-675-0338
Mailing Address - Fax:325-676-5049
Practice Address - Street 1:1933 PINE ST
Practice Address - Street 2:SUITE B
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2431
Practice Address - Country:US
Practice Address - Phone:325-675-0338
Practice Address - Fax:325-676-5049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC15812Medicare UPIN
TX00L43WMedicare PIN