Provider Demographics
NPI:1194732842
Name:FULLER, MICHAEL P (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
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 1:3009 N BALLAS RD STE 227A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2308
Mailing Address - Country:US
Mailing Address - Phone:314-996-7800
Mailing Address - Fax:
Practice Address - Street 1:3009 N BALLAS RD STE 227A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2308
Practice Address - Country:US
Practice Address - Phone:314-996-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106117207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205142003Medicaid
MO205142003Medicaid
008012616Medicare ID - Type Unspecified