Healthcare Provider Details

I. General information

NPI: 1255382495
Provider Name (Legal Business Name): KEITH FULLING M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 OFFICE PKWY
SAINT LOUIS MO
63141-7103
US

IV. Provider business mailing address

660 OFFICE PKWY
SAINT LOUIS MO
63141-7103
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-8015
  • Fax: 314-991-0691
Mailing address:
  • Phone: 314-251-4715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberR7641
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License NumberR7641
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberR7641
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: