Basic Information
| Provider Information | |||||||||
| NPI: | 1831396654 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DANIEL G. FULLER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2075 EXETER ROAD | ||||||||
| Address2: | SUITE70 | ||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017542020 | ||||||||
| FaxNumber: | 9017569537 | ||||||||
| Practice Location | |||||||||
| Address1: | 2075 EXETER RD | ||||||||
| Address2: | SUITE70 | ||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381383962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017542020 | ||||||||
| FaxNumber: | 9017569537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 09/14/2007 | ||||||||
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| AuthorizedOfficialLastName: | FULLER | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9017542020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0600002014 | TN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.