Provider Demographics
NPI:1891178372
Name:FULLER, REDGY (DO)
Entity Type:Individual
Prefix:
First Name:REDGY
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:984150 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-4150
Mailing Address - Country:US
Mailing Address - Phone:402-559-4081
Mailing Address - Fax:402-559-7372
Practice Address - Street 1:984150 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-4150
Practice Address - Country:US
Practice Address - Phone:402-559-4081
Practice Address - Fax:402-559-7372
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2022-07-21
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Provider Licenses
StateLicense IDTaxonomies
NE8055207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology