Basic Information
| Provider Information | |||||||||
| NPI: | 1356347306 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4351 BOOTH CALLOWAY RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | NORTH RICHLAND HILLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761807378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172841165 | ||||||||
| FaxNumber: | 8172844990 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 NORTH RUFE SNOW DR | ||||||||
| Address2: | |||||||||
| City: | KELLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174313800 | ||||||||
| FaxNumber: | 8173370784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 07/20/2010 | ||||||||
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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 | 207Q00000X | H8646 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.