Provider Demographics
NPI:1730125527
Name:FULLER, KEITH LYLE (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:LYLE
Last Name:FULLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 GATEWAY DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-1500
Mailing Address - Country:US
Mailing Address - Phone:334-741-0075
Mailing Address - Fax:334-741-4075
Practice Address - Street 1:2214 GATEWAY DR
Practice Address - Street 2:SUITE C
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-1500
Practice Address - Country:US
Practice Address - Phone:334-741-0075
Practice Address - Fax:334-741-4075
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO350207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALDO350OtherMEDICAL LICENSE
AL000026574Medicaid
AL51026574OtherBLUE CROSS BLUE SHIELD
AL51026574OtherBLUE CROSS BLUE SHIELD
ALDO350OtherMEDICAL LICENSE
AL000026574Medicaid