Provider Demographics
NPI:1831396654
Name:DANIEL G. FULLER
Entity type:Organization
Organization Name:DANIEL G. FULLER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:901-754-2020
Mailing Address - Street 1:2075 EXETER ROAD
Mailing Address - Street 2:SUITE70
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138
Mailing Address - Country:US
Mailing Address - Phone:901-754-2020
Mailing Address - Fax:901-756-9537
Practice Address - Street 1:2075 EXETER RD
Practice Address - Street 2:SUITE70
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3962
Practice Address - Country:US
Practice Address - Phone:901-754-2020
Practice Address - Fax:901-756-9537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0600002014152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3596711Medicare ID - Type Unspecified