Basic Information
| Provider Information | |||||||||
| NPI: | 1104153063 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | TIMOTHY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 18TH ST E STE 400 | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293533422 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1641 MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293532284 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2009 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | MED-PHYS-LIC-103773 | MT | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | MED-PHYS-LIC-103773 | MT | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 085351 | GA | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.