Provider Demographics
NPI:1679515589
Name:FULLER, MAYNARD DARVY (MD)
Entity Type:Individual
Prefix:DR
First Name:MAYNARD
Middle Name:DARVY
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:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-437-9605
Practice Address - Street 1:150 S ROADRUNNER PKWY
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-7044
Practice Address - Country:US
Practice Address - Phone:505-556-8600
Practice Address - Fax:505-556-8700
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM97239207RX0202X
TXG4000207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000S2815Medicaid
TX126330307Medicaid
48753001OtherCSHCN
TX8R1442OtherBLUE CROSS OF TEXAS
TX126330301Medicaid
TX140998901Medicaid
TX8R1442OtherBLUE CROSS OF TEXAS
NM343408501Medicare PIN
TX8366M1Medicare PIN
NMP00173850Medicare PIN
TX140998901Medicaid
NM000S2815Medicaid