Provider Demographics
NPI:1023087632
Name:FULLER, DANIEL GUNN (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:GUNN
Last Name:FULLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2211
Mailing Address - Country:US
Mailing Address - Phone:901-722-3319
Mailing Address - Fax:901-722-3394
Practice Address - Street 1:1225 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2211
Practice Address - Country:US
Practice Address - Phone:901-722-3319
Practice Address - Fax:901-722-3394
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNT1170152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN001916913OtherBC BS OF TN
TN3596711Medicare ID - Type UnspecifiedGERMANTOWN LOCATION
TNT74455Medicare UPIN
TN001916913OtherBC BS OF TN
TN3596717Medicare ID - Type UnspecifiedCOLLIERVILLE OFFICE