Basic Information
| Provider Information | |||||||||
| NPI: | 1962441444 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | EARL | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 BUSINESS PARK DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234626335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579621083 | ||||||||
| FaxNumber: | 7579621254 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 FAIRVIEW DR | ||||||||
| Address2: | SUITE E | ||||||||
| City: | FRANKLIN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238511226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575620383 | ||||||||
| FaxNumber: | 7579621254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 10/30/2008 | ||||||||
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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 | 207RC0000X | 0101019245 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 005848067 | 05 | VA | MEDICAID | 33684 | 01 | VA | OPTIMA HEALTH PLAN | OTHER | 433816 | 01 | VA | ANTHEM BC/BS AND HKP | OTHER | 89063U1 | 05 | NC | MEDICAID | 398492 | 01 | VA | MAMSI | OTHER |