Provider Demographics
NPI:1528025582
Name:FULLER, BRIDGETTE D (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIDGETTE
Middle Name:D
Last Name:FULLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:BRIDGETTE
Other - Middle Name:D
Other - Last Name:DOWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:12701 RESEARCH BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-4325
Mailing Address - Country:US
Mailing Address - Phone:512-258-2020
Mailing Address - Fax:512-258-7835
Practice Address - Street 1:925 STARWOOD DR
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-4325
Practice Address - Country:US
Practice Address - Phone:512-327-7000
Practice Address - Fax:512-259-3802
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6991TG152W00000X
VA0618001388152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX263010YMP3OtherMEDICARE
PA055443Medicare ID - Type Unspecified
TX263010YMP3OtherMEDICARE