Provider Demographics
NPI:1922054725
Name:FULLER, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2122 AVENUE K
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77550-4645
Mailing Address - Country:US
Mailing Address - Phone:409-939-9409
Mailing Address - Fax:409-747-8367
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-0190
Practice Address - Country:US
Practice Address - Phone:409-747-9722
Practice Address - Fax:409-747-8367
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH62262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139588114OtherCIDC TPI
TXE32884Medicare UPIN