MEDICARE: RICHARD E FULLER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0505X	Adult Medicine Physician	32988-020	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1306841002	OTHER	WI	BCBS

General Provider Information

NPI Number	:	1306841002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD E FULLER MD

Provider Business Mailing Address
First Line	:	17780 VERSAILLES CT
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53045-5026
Country	:	US
Telephone Number	:	262-389-1375
Fax Number	:

Provider Business Practice Location Address
First Line	:	17780 VERSAILLES CT
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53045-5026
Country	:	US
Telephone Number	:	262-389-1375
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	06/11/2021

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