Healthcare Provider Details

I. General information

NPI: 1104153063
Provider Name (Legal Business Name): TIMOTHY FULLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2009
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1641 MADISON AVE
TIFTON GA
31794-3757
US

IV. Provider business mailing address

907 18TH ST E STE 400
TIFTON GA
31794-3684
US

V. Phone/Fax

Practice location:
  • Phone: 229-353-2284
  • Fax:
Mailing address:
  • Phone: 229-353-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMED-PHYS-LIC-103773
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number085351
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number085351
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMED-PHYS-LIC-103773
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: