Provider Demographics
NPI:1356387187
Name:FULLER, NEEMA A (MD)
Entity type:Individual
Prefix:
First Name:NEEMA
Middle Name:A
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NEEMA
Other - Middle Name:A
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:133 BENMORE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-4111
Mailing Address - Country:US
Mailing Address - Phone:407-646-7070
Mailing Address - Fax:407-646-7747
Practice Address - Street 1:133 BENMORE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-4111
Practice Address - Country:US
Practice Address - Phone:407-646-7070
Practice Address - Fax:407-646-7747
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69383207Q00000X
CAC54745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250867200Medicaid
FL09019OtherBCBS
P00072466OtherRAILROAD MEDICARE
P00072466OtherRAILROAD MEDICARE
FL09019YMedicare PIN
FL09019OtherBCBS