Provider Demographics
NPI:1982805909
Name:FULLER, JAMES LESLIE (M D)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:LESLIE
Last Name:FULLER
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95604-0707
Mailing Address - Country:US
Mailing Address - Phone:530-885-8755
Mailing Address - Fax:
Practice Address - Street 1:205 S LEE ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3913
Practice Address - Country:US
Practice Address - Phone:229-924-4035
Practice Address - Fax:229-924-2737
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32611207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA35002Medicare UPIN