Provider Demographics
NPI:1457379802
Name:FULLERTON, HEATHER DENKHAUS (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:DENKHAUS
Last Name:FULLERTON
Suffix:
Gender:F
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 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-1032
Practice Address - Country:US
Practice Address - Phone:512-509-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301355208100000X
TXL6029208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
576657OtherCIGNA
1354GOtherBCBS
198455OtherMEDCOST
P00315775OtherMEDICARE RAILROAD
806538OtherPARTNERS
2300598OtherUNITED HEALTHCARE
77686389OtherAETNA
NC891354GMedicaid
2024147AMedicare PIN
H17700Medicare UPIN
2024147Medicare PIN