Provider Demographics
NPI:1760592216
Name:FULLER, PHILIP S (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:S
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 99213
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0213
Mailing Address - Country:US
Mailing Address - Phone:682-885-1860
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:2727 E SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6613
Practice Address - Country:US
Practice Address - Phone:682-885-6000
Practice Address - Fax:682-885-6050
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0922207PP0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137345805Medicaid
1669442042OtherGRP NPI NUMBER
TX5308017OtherAETNA PIN
TX103990OtherSUPERIOR PIN
TX113139100OtherFIRSTCARE PIN
TX133760203Medicaid
TX137283103Medicaid
TX1640383OtherFIRSTHEALTH PIN
TX10028753OtherAMERIGROUP PIN
TX6589933OtherCIGNA PIN
TX544799OtherUHC PIN
TX00L42VOtherBCBSTX GRP PIN
TX413456OtherPHCS PIN
TX88V502OtherBCBSTX IND PIN
TX133760206Medicaid
TX103990OtherSUPERIOR PIN
TX413456OtherPHCS PIN
TX137283103Medicaid