MEDICARE: DR. WILLIAM TYLER FULLER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RP1001X	Pulmonary Disease Physician	29088	MS
2	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	29088	MS
3	207R00000X	Internal Medicine Physician	T-3564	MS

General Provider Information

NPI Number	:	1205323177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM TYLER FULLER MD

Provider Business Mailing Address
First Line	:	5959 S SHERWOOD FOREST BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-6038
Country	:	US
Telephone Number	:	225-765-5727
Fax Number	:	225-765-9196

Provider Business Practice Location Address
First Line	:	971 LAKELAND DR STE 1052
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39216-4609
Country	:	US
Telephone Number	:	601-981-9503
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2018
Last Update Date	:	12/11/2025

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