Provider Demographics
NPI:1659655017
Name:FULLER, ELISA J (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:J
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:8035 N 85TH WAY
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4321
Mailing Address - Country:US
Mailing Address - Phone:480-304-9234
Mailing Address - Fax:480-907-2011
Practice Address - Street 1:8035 N 85TH WAY
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4321
Practice Address - Country:US
Practice Address - Phone:480-304-9234
Practice Address - Fax:480-907-2011
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ259282084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry