Healthcare Provider Details

I. General information

NPI: 1588955215
Provider Name (Legal Business Name): JUSTIN TIMOTHY FULLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2209 JOHN R WOODEN DR
MARTINSVILLE IN
46151-1840
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-2819
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01072688A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: