Provider Demographics
NPI:1790764835
Name:FULLER, COLLEEN C (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:C
Last Name:FULLER
Suffix:
Gender:F
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 52448
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-2448
Mailing Address - Country:US
Mailing Address - Phone:318-797-1743
Mailing Address - Fax:
Practice Address - Street 1:1945 E 70TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5347
Practice Address - Country:US
Practice Address - Phone:318-797-1743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014708207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1938271Medicaid
LA5R163Medicare ID - Type Unspecified
LA1938271Medicaid