Provider Demographics
NPI:1669481453
Name:FULLER, TERRY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:WAYNE
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 1:2121 PEASE ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-8321
Mailing Address - Country:US
Mailing Address - Phone:956-440-7494
Mailing Address - Fax:956-440-8301
Practice Address - Street 1:2121 PEASE ST STE 2C
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8321
Practice Address - Country:US
Practice Address - Phone:956-440-7494
Practice Address - Fax:956-440-8301
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK07592084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000U84VMedicaid
TXP000U84VMedicaid
TX00U84VMedicare ID - Type Unspecified