Provider Demographics
NPI:1487694790
Name:FULLER, BRYAN DALE (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:DALE
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 1:625 UNITED DR STE 330
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-7828
Mailing Address - Country:US
Mailing Address - Phone:501-499-8300
Mailing Address - Fax:501-379-8428
Practice Address - Street 1:625 UNITED DR STE 220
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-7835
Practice Address - Country:US
Practice Address - Phone:501-499-8300
Practice Address - Fax:501-379-8428
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4442207V00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5N365OtherBLUE/CROSS PROVIDER NO.
AR5N365Medicare PIN