Basic Information
| Provider Information | |||||||||
| NPI: | 1285713156 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1340 HAL GREER BLVD | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045262200 | ||||||||
| FaxNumber: | 3043991507 | ||||||||
| Practice Location | |||||||||
| Address1: | 1340 HAL GREER BLVD | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045262200 | ||||||||
| FaxNumber: | 3043996726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 21688 | WV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | TP578 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 21688 | WV | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207P00000X | 21688 | WV | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | BF9296509 | 01 | WV | DEA NUMBER | OTHER | 7100048840 | 05 | KY | MEDICAID | 1285713156 | 05 | WV | MEDICAID | 2783519 | 05 | OH | MEDICAID |