Provider Demographics
NPI:1508867672
Name:FULLER, WAYNE TEMPLETON (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:TEMPLETON
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 1:628 THALIA POINT RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1816
Mailing Address - Country:US
Mailing Address - Phone:757-672-8367
Mailing Address - Fax:
Practice Address - Street 1:628 THALIA POINT RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1816
Practice Address - Country:US
Practice Address - Phone:757-672-8367
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034109207Q00000X
NC31285207Q00000X
WI38697207Q00000X
SC19181207Q00000X
UT339571-1205207Q00000X
CAG084432207Q00000X
AZ26099207Q00000X
WA00035725207Q00000X
CO37054207Q00000X
NM99-44207Q00000X
WY6222A207Q00000X
MN42646207Q00000X
MDD56565207Q00000X
IDM-8300207Q00000X
VT207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11104815OtherCAQH PROVIDER ID
C83926Medicare UPIN