Provider Demographics
NPI:1568463487
Name:FULLERTON, BRADLEY DEAN (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DEAN
Last Name:FULLERTON
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 1:2714 BEE CAVES RD STE 106
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-5672
Mailing Address - Country:US
Mailing Address - Phone:512-347-7246
Mailing Address - Fax:512-347-7245
Practice Address - Street 1:2714 BEE CAVES RD
Practice Address - Street 2:SUITE 106
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-5677
Practice Address - Country:US
Practice Address - Phone:512-347-7246
Practice Address - Fax:512-347-7245
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2025-02-05
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
TXK3731208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110711203Medicaid
TXG54776Medicare UPIN
TX110711203Medicaid