Provider Demographics
NPI:1518620186
Name:FULLER, JOHN THOMAS (IDHS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:FULLER
Suffix:
Gender:M
Credentials:IDHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12239 CRESSIDA LOOP
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-9001
Mailing Address - Country:US
Mailing Address - Phone:205-901-4498
Mailing Address - Fax:
Practice Address - Street 1:12239 CRESSIDA LOOP
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-9001
Practice Address - Country:US
Practice Address - Phone:205-901-4498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman