Provider Demographics
NPI:1598871345
Name:FULLER, PEGGY A (MD)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:A
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 CLEMENT AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2431
Mailing Address - Country:US
Mailing Address - Phone:704-370-2700
Mailing Address - Fax:704-370-2702
Practice Address - Street 1:353 CLEMENT AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2431
Practice Address - Country:US
Practice Address - Phone:704-370-2700
Practice Address - Fax:704-370-2702
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700555174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9700555OtherSTATE LICENSE NUMBER
G52520Medicare UPIN