Provider Demographics
NPI:1992703649
Name:FULLER, GEORGE H (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:H
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4809 AMBASSADOR CAFFERY PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6917
Mailing Address - Country:US
Mailing Address - Phone:337-981-6100
Mailing Address - Fax:337-988-8751
Practice Address - Street 1:4630 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:STE 208
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6949
Practice Address - Country:US
Practice Address - Phone:337-981-6100
Practice Address - Fax:337-988-8751
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA016330207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
160019227OtherPALMETTO GBA - RAILROAD M
LA1348783Medicaid
160019227OtherPALMETTO GBA - RAILROAD M
B60294Medicare UPIN
LA1348783Medicaid