Provider Demographics
NPI:1134149081
Name:FULLER III, IRA BUTLER III (MD)
Entity type:Individual
Prefix:DR
First Name:IRA
Middle Name:BUTLER
Last Name:FULLER III
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-3743
Mailing Address - Country:US
Mailing Address - Phone:225-924-6820
Mailing Address - Fax:225-928-5334
Practice Address - Street 1:433 PLAZA ST
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3729
Practice Address - Country:US
Practice Address - Phone:985-730-6705
Practice Address - Fax:985-730-6709
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06356R207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1341428Medicaid
LAB02640Medicare UPIN
LA1341428Medicaid
5M308DD21Medicare PIN