Healthcare Provider Details

I. General information

NPI: 1083159529
Provider Name (Legal Business Name): FULLER DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 PASADENA AVE S STE 4C
SOUTH PASADENA FL
33707
US

IV. Provider business mailing address

1609 PASADENA AVE S STE 4C
SOUTH PASADENA FL
33707-4564
US

V. Phone/Fax

Practice location:
  • Phone: 727-347-7524
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberME99153
License Number StateFL

VIII. Authorized Official

Name: DR. BRUCE W. FULLER
Title or Position: OWNER
Credential: MD
Phone: 727-347-7524