Basic Information
| Provider Information | |||||||||
| NPI: | 1821217746 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | ITHIEL | ||||||||
| MiddleName: | LOKEN AMES | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 POMFRET ST | ||||||||
| Address2: | |||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062601836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027608259 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17 BELMONT AVE | ||||||||
| Address2: | ANESTHESIOLOGY DEPT | ||||||||
| City: | BRATTLEBORO | ||||||||
| State: | VT | ||||||||
| PostalCode: | 053017601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022578220 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 0420011774 | VT | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 67242 | CT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.