Provider Demographics
NPI:1962441444
Name:FULLER, EARL W JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EARL
Middle Name:W
Last Name:FULLER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:205 BUSINESS PARK DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-6335
Mailing Address - Country:US
Mailing Address - Phone:757-962-1083
Mailing Address - Fax:757-962-1254
Practice Address - Street 1:102 FAIRVIEW DR
Practice Address - Street 2:SUITE E
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-1226
Practice Address - Country:US
Practice Address - Phone:757-562-0383
Practice Address - Fax:757-962-1254
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-10-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101019245207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005848067Medicaid
VA33684OtherOPTIMA HEALTH PLAN
VA433816OtherANTHEM BC/BS AND HKP
NC89063U1Medicaid
VA398492OtherMAMSI
VA060062472Medicare PIN
VAD52549Medicare UPIN
VA005848067Medicaid