Provider Demographics
NPI:1891157129
Name:FULLER, COLLIN GUTHRIE (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLIN
Middle Name:GUTHRIE
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 1:2310 E ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-4401
Mailing Address - Country:US
Mailing Address - Phone:215-427-1111
Mailing Address - Fax:
Practice Address - Street 1:833 CHESTNUT ST STE 740
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4409
Practice Address - Country:US
Practice Address - Phone:215-955-6680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD471086207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology