Provider Demographics
NPI:1609854744
Name:FULLER, GARRY T (DC)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:T
Last Name:FULLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 N GREEN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-2421
Mailing Address - Country:US
Mailing Address - Phone:317-852-8885
Mailing Address - Fax:317-852-7492
Practice Address - Street 1:515 N GREEN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-2421
Practice Address - Country:US
Practice Address - Phone:317-852-8885
Practice Address - Fax:317-852-7492
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001100111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100133800AMedicaid
IN260000AMedicare UPIN
INT34684Medicare UPIN