Provider Demographics
NPI:1669433645
Name:FULLER, ELIZABETH A (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2038
Mailing Address - Country:US
Mailing Address - Phone:508-885-9737
Mailing Address - Fax:508-885-6139
Practice Address - Street 1:407 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:MA
Practice Address - Zip Code:01562-1909
Practice Address - Country:US
Practice Address - Phone:508-885-9737
Practice Address - Fax:508-885-6139
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2017-08-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA75454207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1150053OtherFIRST HEALTH
MA1669433645OtherBLUE CROSS BLUE SHIELD OF MA
042472266OtherPRIVATE HEALTHCARE SYSTEM
J12908OtherBLUE SHIELD INDEMNITY
042472266OtherONE HEALTH PLAN
9143201OtherCIGNA HEALTH PLAN
9900893OtherFALLON COMMUNITY HEALTH P
4545003OtherAETNA US HEALTHCARE
AA1214OtherHARVARD PILGRIM HEALTHCAR
MA1669433645OtherTUFTS HEALTH PLAN
MA3104796Medicaid
9900893OtherFALLON COMMUNITY HEALTH P
MAJ12908Medicare ID - Type Unspecified
MA1669433645OtherTUFTS HEALTH PLAN
J12908Medicare ID - Type UnspecifiedMEDICARE B
042472266OtherHEALTHCARE VALUE MANAGEME
26817OtherCHILDRENS MEDICAL SECURIT
9900893OtherFALLON COMMUNITY HEALTH P
J12908OtherBLUE SHIELD INDEMNITY
MA3104796Medicaid