Provider Demographics
NPI:1073582193
Name:FULLER, TERESA (MD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 E UNIVERSITY PKWY UNIT 109
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-2432
Mailing Address - Country:US
Mailing Address - Phone:410-235-1601
Mailing Address - Fax:410-467-6881
Practice Address - Street 1:10084 REISTERSTOWN RD STE 200B
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4096
Practice Address - Country:US
Practice Address - Phone:410-526-7993
Practice Address - Fax:410-526-5144
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2018-12-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD0058861208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD400185100Medicaid
H75189Medicare UPIN