Provider Demographics
NPI:1124513023
Name:FULLER, SPENCER (MD, MPH)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5449 RENO CORPORATE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2626
Mailing Address - Country:US
Mailing Address - Phone:775-737-9411
Mailing Address - Fax:
Practice Address - Street 1:5449 RENO CORPORATE DR STE 200
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-2626
Practice Address - Country:US
Practice Address - Phone:775-737-9411
Practice Address - Fax:775-737-9413
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018020280207W00000X, 207R00000X
UT12685949-1205207W00000X
NV24889207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine