Provider Demographics
NPI:1821073768
Name:FULLER, A. KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:A.
Middle Name:KENNETH
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 1:1913 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5751
Mailing Address - Country:US
Mailing Address - Phone:229-226-7060
Mailing Address - Fax:229-226-7061
Practice Address - Street 1:1913 SMITH AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5751
Practice Address - Country:US
Practice Address - Phone:229-226-7060
Practice Address - Fax:229-226-7061
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0281652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GABF0680810OtherDEA NUMBER
GAD39905Medicare UPIN
GA26BDBVKMedicare ID - Type Unspecified