Provider Demographics
NPI:1578555165
Name:FULLER, COLIN M (MD)
Entity Type:Individual
Prefix:DR
First Name:COLIN
Middle Name:M
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 3046
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-0746
Mailing Address - Country:US
Mailing Address - Phone:775-356-4514
Mailing Address - Fax:
Practice Address - Street 1:2385 E PRATER WAY
Practice Address - Street 2:SUITE 302
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89434-9629
Practice Address - Country:US
Practice Address - Phone:775-356-4514
Practice Address - Fax:775-356-4991
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3987207RC0000X
CAG26986207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
11040349OtherCAQH
1578555165OtherNPI
CAG26986OtherMEDICAL LICENSE
NV3987OtherMEDICAL LICENSE
NV3987OtherMEDICAL LICENSE
CACA114488Medicare PIN
11040349OtherCAQH