Provider Demographics
NPI:1588861397
Name:FULLER, BRUCE W (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:W
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 1:1609 PASADENA AVE S STE 4C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:FL
Mailing Address - Zip Code:33707-4564
Mailing Address - Country:US
Mailing Address - Phone:727-347-7524
Mailing Address - Fax:727-384-6336
Practice Address - Street 1:1609 PASADENA AVE S STE 4C
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-4564
Practice Address - Country:US
Practice Address - Phone:727-347-7524
Practice Address - Fax:727-384-6336
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99153207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology