Provider Demographics
NPI:1760423438
Name:FULLER, STEVEN D (PHD DO)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:D
Last Name:FULLER
Suffix:
Gender:M
Credentials:PHD DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 LOCH HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-3101
Mailing Address - Country:US
Mailing Address - Phone:410-798-4314
Mailing Address - Fax:410-798-4314
Practice Address - Street 1:5401 OLD COURT RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5103
Practice Address - Country:US
Practice Address - Phone:410-798-4314
Practice Address - Fax:410-798-4314
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0036078207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD623806M60Medicare ID - Type Unspecified
B70521Medicare UPIN