Provider Demographics
NPI:1780973982
Name:FULLER, BRIAN J (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
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 1:4685 FOREST AVE C
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-3359
Mailing Address - Country:US
Mailing Address - Phone:513-853-4731
Mailing Address - Fax:513-852-8525
Practice Address - Street 1:7810 5 MILE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-2356
Practice Address - Country:US
Practice Address - Phone:513-246-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.124187207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH12051983OtherOTHER
OH0124895Medicaid
OHH411201Medicare PIN