Provider Demographics
NPI:1780680439
Name:FULLER, CHARLES W (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1933 PINE ST
Mailing Address - Street 2:STE B
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-2431
Mailing Address - Country:US
Mailing Address - Phone:325-675-0338
Mailing Address - Fax:325-676-5049
Practice Address - Street 1:1933 PINE ST
Practice Address - Street 2:STE B
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2431
Practice Address - Country:US
Practice Address - Phone:325-675-0338
Practice Address - Fax:325-676-5049
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXF3971207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140117607Medicaid
TX140117624Medicaid
TX113131101OtherFIRST CARE HMO
TX140117624Medicaid
TXC15812Medicare UPIN