Provider Demographics
NPI:1932169893
Name:FULLER, RONALD (MS)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 E 53RD ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2710
Mailing Address - Country:US
Mailing Address - Phone:563-359-3949
Mailing Address - Fax:
Practice Address - Street 1:1970 E 53RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2710
Practice Address - Country:US
Practice Address - Phone:563-359-3949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA320812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1187187OtherMEDICAID IOWA W/ ORA
IAK51666OtherMEDICARE FOR ORA
IA20765OtherBCBS OF IOWA W/ ORA
IA4187487Medicaid
IA300121312OtherRAILROAD MEDICARE W/ ORA
32985OtherBCBS IA FOR RGPCSC
300095837OtherRR MDC FOR RGPCSC
IA20765OtherMEDICARE W/ ORA
300132299OtherRR MDC FOR RGIC LLC
49669OtherBCBS IA FOR RGIC LLC
IA0187187Medicaid
32985OtherBCBS IA FOR RGPCSC
IA20765OtherMEDICARE W/ ORA
G94149Medicare UPIN