Healthcare Provider Details

I. General information

NPI: 1679515589
Provider Name (Legal Business Name): MAYNARD DARVY FULLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 05/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S ROADRUNNER PKWY
LAS CRUCES NM
88011-7044
US

IV. Provider business mailing address

PO BOX 911230
DALLAS TX
75391-1230
US

V. Phone/Fax

Practice location:
  • Phone: 505-556-8600
  • Fax: 505-556-8700
Mailing address:
  • Phone: 972-997-8000
  • Fax: 972-437-9605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number97239
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberG4000
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: