Healthcare Provider Details

I. General information

NPI: 1962441444
Provider Name (Legal Business Name): EARL W FULLER JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 FAIRVIEW DR SUITE E
FRANKLIN VA
23851-1226
US

IV. Provider business mailing address

205 BUSINESS PARK DRIVE SUITE 200
VIRGINIA BEACH VA
23462-6335
US

V. Phone/Fax

Practice location:
  • Phone: 757-562-0383
  • Fax: 757-962-1254
Mailing address:
  • Phone: 757-962-1083
  • Fax: 757-962-1254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101019245
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: