Provider Demographics
NPI:1386808376
Name:BRUCE E. FULLER, M.D, PLLC
Entity type:Organization
Organization Name:BRUCE E. FULLER, M.D, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:EVANS
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-872-7787
Mailing Address - Street 1:PO BOX 2579
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23609-0579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12695 MCMANUS BLVD
Practice Address - Street 2:BLDG 3, SUITE B
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4435
Practice Address - Country:US
Practice Address - Phone:757-872-7787
Practice Address - Fax:757-872-7727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045701174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty