Provider Demographics
NPI:1689761041
Name:FULLER, WAYNE B (OD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:B
Last Name:FULLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 2ND AVE SE
Mailing Address - Street 2:P. O. BOX 1067
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-3514
Mailing Address - Country:US
Mailing Address - Phone:256-734-1121
Mailing Address - Fax:256-734-1991
Practice Address - Street 1:210 2ND AVE SE
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-3514
Practice Address - Country:US
Practice Address - Phone:256-734-1121
Practice Address - Fax:256-734-1991
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS320TA285152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51521397OtherBCBS
AL051554145Medicare ID - Type Unspecified
ALT68915Medicare UPIN