Provider Demographics
NPI:1396972386
Name:FULLER, BRIAN C (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:C
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 1:4780 N JOSEY LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4615
Mailing Address - Country:US
Mailing Address - Phone:972-492-1334
Mailing Address - Fax:972-492-7909
Practice Address - Street 1:4780 N JOSEY LN
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4615
Practice Address - Country:US
Practice Address - Phone:972-492-1334
Practice Address - Fax:972-492-7909
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2020-06-29
Deactivation Date:2019-08-21
Deactivation Code:
Reactivation Date:2019-09-26
Provider Licenses
StateLicense IDTaxonomies
NE25870207X00000X, 207X00000X
IL036144916207XS0114X
TXR8564207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8LJ360OtherBCBS