Provider Demographics
NPI:1982696159
Name:FULLER, LETA R (MD)
Entity Type:Individual
Prefix:
First Name:LETA
Middle Name:R
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 E 10TH AVE STE 172
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2884
Mailing Address - Country:US
Mailing Address - Phone:801-408-5155
Mailing Address - Fax:
Practice Address - Street 1:4401 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3195
Practice Address - Country:US
Practice Address - Phone:801-387-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2024-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6000865-12052080N0001X
OH350732462080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2140178Medicaid
KY64060502Medicaid
OH2140178Medicaid
H59957Medicare UPIN