Healthcare Provider Details

I. General information

NPI: 1497822845
Provider Name (Legal Business Name): TIMOTHY LOUIS FULLER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 EAST VANN ROAD
GREENEVILLE TN
37743-7202
US

IV. Provider business mailing address

PO BOX 15004
KNOXVILLE TN
37901
US

V. Phone/Fax

Practice location:
  • Phone: 423-278-1950
  • Fax: 423-278-1973
Mailing address:
  • Phone: 865-522-9730
  • Fax: 865-637-2520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1343
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: