Provider Demographics
NPI:1538117890
Name:FULLER, BRUCE EVANS (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:EVANS
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BRUCE
Other - Middle Name:E
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2579
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23609-0579
Mailing Address - Country:US
Mailing Address - Phone:757-872-7787
Mailing Address - Fax:757-872-7727
Practice Address - Street 1:885 KEMPSVILLE RD STE 309
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3800
Practice Address - Country:US
Practice Address - Phone:757-461-1033
Practice Address - Fax:757-299-4949
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045701207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA070000256Medicare ID - Type Unspecified
VAG05952Medicare UPIN