Provider Demographics
NPI:1770807786
Name:FULLER, ANDREW JOSEPH SR (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:JOSEPH
Last Name:FULLER
Suffix:SR
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 1:1514 JEFFERSON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5520
Practice Address - Country:US
Practice Address - Phone:985-646-5189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-19
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA204996207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06059043Medicaid
LA2106546Medicaid
LA349281YH3UMedicare PIN