Provider Demographics
NPI:1922022110
Name:FULLER, EDWIN R III (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:R
Last Name:FULLER
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:7024 BURNETT-WOMACK BUILDING
Mailing Address - Street 2:CB#7155
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27599-0001
Mailing Address - Country:US
Mailing Address - Phone:919-966-2561
Mailing Address - Fax:919-966-4251
Practice Address - Street 1:7024 BURNETT-WOMACK BUILDING
Practice Address - Street 2:CB#7155
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-0001
Practice Address - Country:US
Practice Address - Phone:919-966-2561
Practice Address - Fax:919-966-4251
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-05-08
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Provider Licenses
StateLicense IDTaxonomies
NC0501405207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901671Medicaid
NC5901671Medicaid
NCI39600Medicare UPIN