Basic Information
| Provider Information | |||||||||
| NPI: | 1235159310 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9724379605 | ||||||||
| Practice Location | |||||||||
| Address1: | 12221 MERIT DRIVE | ||||||||
| Address2: | #500 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724902900 | ||||||||
| FaxNumber: | 9723860261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | D4659 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 139559204 | 05 | TX | MEDICAID | 139559206 | 05 | TX | MEDICAID | 139559202 | 05 | TX | MEDICAID | 139559214 | 05 | TX | MEDICAID | 139559210 | 05 | TX | MEDICAID | 139559201 | 05 | TX | MEDICAID | 139559207 | 05 | TX | MEDICAID | 139559208 | 05 | TX | MEDICAID | 139559211 | 05 | TX | MEDICAID | 139559212 | 05 | TX | MEDICAID | 139559205 | 05 | TX | MEDICAID | 139559203 | 01 | TX | CSHCN | OTHER | 8R1441 | 01 | TX | BLUE CROSS OF TX | OTHER |