Provider Demographics
NPI:1154379766
Name:FULLER, THOMAS (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2B HAW CREEK LN
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28805-2250
Mailing Address - Country:US
Mailing Address - Phone:828-298-0854
Mailing Address - Fax:828-298-2738
Practice Address - Street 1:2B HAW CREEK LN
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28805-2250
Practice Address - Country:US
Practice Address - Phone:828-298-0854
Practice Address - Fax:828-298-2738
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1477152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC22-71413OtherUNITED HEALTHCARE
NC890907HMedicaid
NC0907HOtherBLUE CROSS BLUE SHIELD
NCU40303Medicare UPIN
NC2468611BMedicare ID - Type UnspecifiedPROVIDER NUMBER