Provider Demographics
NPI:1336240555
Name:FULLER, EVERETT P (MD)
Entity Type:Individual
Prefix:MR
First Name:EVERETT
Middle Name:P
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 1:135 COMMONWEALTH DRIVE, SUITE 230
Mailing Address - Street 2:135 COMMONWEALTH WOMEN'S CARE
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615
Mailing Address - Country:US
Mailing Address - Phone:864-365-0250
Mailing Address - Fax:864-365-0251
Practice Address - Street 1:135 COMMONWEALTH DR
Practice Address - Street 2:SUITE 300
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4831
Practice Address - Country:US
Practice Address - Phone:864-675-1190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC111499207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCC60843Medicare UPIN
SC8157Medicare ID - Type UnspecifiedMEDICARE