Provider Demographics
NPI:1184623639
Name:FULLER, DWAIN (MD )
Entity type:Individual
Prefix:
First Name:DWAIN
Middle Name:
Last Name:FULLER
Suffix:
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:PO BOX 650037
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0037
Mailing Address - Country:US
Mailing Address - Phone:214-696-2008
Mailing Address - Fax:
Practice Address - Street 1:9600 N. CENTRAL EXPRESSWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5078
Practice Address - Country:US
Practice Address - Phone:214-692-6941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD3227207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129267407Medicaid
TX129267408Medicaid
TX129267409Medicaid
TXC15814Medicare UPIN
TX8G0119Medicare PIN
TX8G0118Medicare PIN
TX129267408Medicaid
TX8G0117Medicare PIN