Provider Demographics
NPI:1356424899
Name:FULLER, RAYMOND D (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:D
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 1:5400 FRANTZ RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 E WILLIAM ST
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-2149
Practice Address - Country:US
Practice Address - Phone:740-615-0450
Practice Address - Fax:740-615-0462
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35061615208600000X
OH35.061615174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0165182Medicaid
G03878Medicare UPIN
OH0782895Medicare PIN
FU0782894Medicare PIN