Basic Information
| Provider Information | |||||||||
| NPI: | 1396972386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4780 N JOSEY LN | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750104615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724921334 | ||||||||
| FaxNumber: | 9724927909 | ||||||||
| Practice Location | |||||||||
| Address1: | 4780 N JOSEY LN | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750104615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724921334 | ||||||||
| FaxNumber: | 9724927909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2009 | ||||||||
| LastUpdateDate: | 06/29/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/21/2019 | ||||||||
| NPIReactivationDate: | 09/26/2019 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 25870 | NE | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 036144916 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XS0114X | R8564 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8LJ360 | 01 | TX | BCBS | OTHER |