Healthcare Provider Details

I. General information

NPI: 1376578252
Provider Name (Legal Business Name): HAROLD JONES FULLER JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 03/03/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 SERPENTINE DR SUITE 400
SPARTANBURG SC
29303-3096
US

IV. Provider business mailing address

PO BOX 743070
ATLANTA GA
30374-3070
US

V. Phone/Fax

Practice location:
  • Phone: 864-560-7517
  • Fax: 864-560-7520
Mailing address:
  • Phone: 864-560-4304
  • Fax: 864-560-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2001-01044
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number200101044
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number38586
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number38586
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: