Healthcare Provider Details

I. General information

NPI: 1538235502
Provider Name (Legal Business Name): BRIAN J. FULLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2373 CENTRAL PARK BLVD SUITE 303
DENVER CO
80238-2300
US

IV. Provider business mailing address

3087 TEJON ST SPT C
DENVER CO
80211-3976
US

V. Phone/Fax

Practice location:
  • Phone: 720-220-7857
  • Fax: 303-287-7357
Mailing address:
  • Phone: 720-220-7857
  • Fax: 303-320-2934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number46857
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number46857
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: