Provider Demographics
NPI:1124055561
Name:FULLER, MARK AVERY (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:AVERY
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:AVERY
Other - Last Name:MOORE-FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:638 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-1424
Mailing Address - Country:US
Mailing Address - Phone:906-364-7105
Mailing Address - Fax:
Practice Address - Street 1:36745 AIKEN RD
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:WI
Practice Address - Zip Code:54814-4579
Practice Address - Country:US
Practice Address - Phone:715-779-3707
Practice Address - Fax:715-779-3362
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301093004208M00000X
WI1901-320207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3536500Medicaid