Provider Demographics
NPI:1710909288
Name:FULLWOOD, PHILLIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:FULLWOOD
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 1:121 S ESTES DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 S ESTES DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-2868
Practice Address - Country:US
Practice Address - Phone:919-913-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC365252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404921Medicaid
2203328DMedicare ID - Type Unspecified
NC3404921Medicaid