Healthcare Provider Details

I. General information

NPI: 1285713156
Provider Name (Legal Business Name): JEREMY D FULLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 03/07/2023
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 HAL GREER BLVD
HUNTINGTON WV
25701-3804
US

IV. Provider business mailing address

1340 HAL GREER BLVD
HUNTINGTON WV
25701-3804
US

V. Phone/Fax

Practice location:
  • Phone: 304-526-2200
  • Fax: 304-399-6726
Mailing address:
  • Phone: 304-526-2200
  • Fax: 304-399-1507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number21688
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21688
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTP578
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number21688
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: