Provider Demographics
NPI:1790830032
Name:FULLER, CHRISTOPHER G (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:G
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 1:4517 98TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-5013
Mailing Address - Country:US
Mailing Address - Phone:806-792-0086
Mailing Address - Fax:806-792-2446
Practice Address - Street 1:4517 98TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-5013
Practice Address - Country:US
Practice Address - Phone:806-792-0086
Practice Address - Fax:806-792-2446
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2009-0622207W00000X
TXM6622207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM08484066Medicaid
TX186504007Medicaid
TX186504009Medicaid
TX186504008Medicaid
TX186504008Medicaid
TX186504009Medicaid
TXTXB136508Medicare PIN
TXP00967900Medicare PIN
TXTXB136505Medicare PIN