Provider Demographics
NPI:1629135942
Name:FULLER, DAVID SCOTT (DC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:SCOTT
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 1:1218 WELSH RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-2055
Mailing Address - Country:US
Mailing Address - Phone:215-393-1117
Mailing Address - Fax:215-393-4464
Practice Address - Street 1:1218 WELSH RD
Practice Address - Street 2:SUITE C
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-2055
Practice Address - Country:US
Practice Address - Phone:215-393-1117
Practice Address - Fax:215-393-4464
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC008807111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2081687000OtherIBC