Healthcare Provider Details

I. General information

NPI: 1154379766
Provider Name (Legal Business Name): THOMAS FULLER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2B HAW CREEK LN
ASHEVILLE NC
28805-2250
US

IV. Provider business mailing address

2B HAW CREEK LN
ASHEVILLE NC
28805-2250
US

V. Phone/Fax

Practice location:
  • Phone: 828-298-0854
  • Fax: 828-298-2738
Mailing address:
  • Phone: 828-298-0854
  • Fax: 828-298-2738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1477
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1477
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number1477
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: