Provider Demographics
NPI:1659378511
Name:FULLER, MARK G (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
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 1:1307 FEDERAL ST STE 301
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-4769
Mailing Address - Country:US
Mailing Address - Phone:412-359-3751
Mailing Address - Fax:412-442-2335
Practice Address - Street 1:1307 FEDERAL ST STE 301
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-4769
Practice Address - Country:US
Practice Address - Phone:412-359-3751
Practice Address - Fax:412-442-2335
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043300L207R00000X, 2084P0802X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001049024Medicaid