Provider Demographics
NPI:1558379388
Name:FULLER, MICHAEL F (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:F
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:PO BOX 2564
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31203
Mailing Address - Country:US
Mailing Address - Phone:478-746-5644
Mailing Address - Fax:478-745-4849
Practice Address - Street 1:380 HOSPITAL DR
Practice Address - Street 2:SUITE 410
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217
Practice Address - Country:US
Practice Address - Phone:478-746-5644
Practice Address - Fax:478-745-4849
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057971207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA823068501CMedicaid
GA823068501DMedicaid
GAP00331784OtherRAILROAD MEDICARE
GA355662OtherWELLCARE
GA823068501AMedicaid
GA823068501EMedicaid
GA823068501CMedicaid
GA823068501EMedicaid
GA823068501DMedicaid