Healthcare Provider Details

I. General information

NPI: 1225080765
Provider Name (Legal Business Name): JON D FULLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603-2 N PROGRESS AVE STE 200
SILOAM SPRINGS AR
72761-4206
US

IV. Provider business mailing address

603-2 N PROGRESS AVE STE 200
SILOAM SPRINGS AR
72761-4206
US

V. Phone/Fax

Practice location:
  • Phone: 479-215-3040
  • Fax: 479-238-1182
Mailing address:
  • Phone: 479-215-3040
  • Fax: 479-238-1182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberE4323
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: