Provider Demographics
NPI:1912010570
Name:FULLER, CYNTHIA J (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:J
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 S HARVARD AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4520 S HARVARD AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2925
Practice Address - Country:US
Practice Address - Phone:918-743-3224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK177112080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics