Provider Demographics
NPI:1104898592
Name:FULLER, BRYAN H (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:H
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-8681
Mailing Address - Fax:740-353-7900
Practice Address - Street 1:1005 E RING RD
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-9610
Practice Address - Country:US
Practice Address - Phone:740-534-9830
Practice Address - Fax:740-534-9832
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35078023207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2191453Medicaid
KY000000634705OtherANTHEM BCBS
KY000000653707OtherANTHEM BCBS
KY000000380360OtherANTHEM BCBS
KY000000594108OtherANTHEM BCBS
KY64022601Medicaid
OH2191453Medicaid
KY01258004Medicare PIN
OH4030163Medicare PIN
KY000000634705OtherANTHEM BCBS
OHP00296975Medicare PIN