Provider Demographics
NPI:1154596948
Name:DR LAWRENCE P FULLER OD
Entity type:Organization
Organization Name:DR LAWRENCE P FULLER OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST SOLE PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:P
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:407-846-2020
Mailing Address - Street 1:703 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-5265
Mailing Address - Country:US
Mailing Address - Phone:407-846-2020
Mailing Address - Fax:407-846-8039
Practice Address - Street 1:703 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5265
Practice Address - Country:US
Practice Address - Phone:407-846-2020
Practice Address - Fax:407-846-8039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC797152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0747320001Medicare NSC