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General NPI Number Information
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NPI Number | 1386808376
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Entity Type | Organization
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Legal Business Name | BRUCE E. FULLER, M.D, PLLC
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Dates
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Enumeration Date | 07/18/2008
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Last Update Date | 07/18/2008
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Provider Practice Location Address
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Address Line | 12695 MCMANUS BLVD BLDG 3, SUITE B
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City | NEWPORT NEWS
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State | VA
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Zip | 23602-4435
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Country | US
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Telephone | 757-872-7787
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Fax | 757-872-7727
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Provider Business Mailing Address
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Address Line | PO BOX 2579
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City | NEWPORT NEWS
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State | VA
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Zip | 23609-0579
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DERMATOLOGIST
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Name | DR. BRUCE EVANS FULLER
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Credential | M.D.
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Telephone | 757-872-7787
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 0101045701
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License Number State | VA
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