Provider Demographics
NPI:1932766060
Name:FULLER, MYRON ELLIOT (MD)
Entity type:Individual
Prefix:DR
First Name:MYRON
Middle Name:ELLIOT
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1919 E HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1975
Mailing Address - Country:US
Mailing Address - Phone:352-717-3755
Mailing Address - Fax:352-717-3756
Practice Address - Street 1:1919 E HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1975
Practice Address - Country:US
Practice Address - Phone:352-717-3755
Practice Address - Fax:352-717-3756
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME154231207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine