Provider Demographics
NPI:1801817267
Name:FULLER, JOHN R (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
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 1:500 VINCENT ST
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-1842
Mailing Address - Country:US
Mailing Address - Phone:715-295-9939
Mailing Address - Fax:
Practice Address - Street 1:500 VINCENT ST
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-1842
Practice Address - Country:US
Practice Address - Phone:715-295-9939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36770020208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00069403OtherRAILROAD MEDICARE PROVIDER NUMBER
WI32166500Medicaid
G08462Medicare UPIN
WI0917050001Medicare NSC
000550105Medicare ID - Type Unspecified