Provider Demographics
NPI:1720469174
Name:FULLER, JOHN BRYANT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRYANT
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:PO BOX 874
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34673-0874
Mailing Address - Country:US
Mailing Address - Phone:904-501-0083
Mailing Address - Fax:727-677-0286
Practice Address - Street 1:5145 DEER PARK DR
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-7013
Practice Address - Country:US
Practice Address - Phone:904-501-0083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME155800207XS0106X
FL390200000X
TX390200000X
NM390200000X
NMMD2024-0084207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMMD2024-0084OtherNM LICENSE