Basic Information
| Provider Information | |||||||||
| NPI: | 1811287816 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10700 E GEDDES AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Practice Location | |||||||||
| Address1: | 10700 E GEDDES AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 2085R0202X | 2016-01080 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 29941 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 04-39828 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | 58155 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 581760YQ33 | 01 | CO | MEDICARE PIN | OTHER | 581760YQN9 | 01 | CO | MEDICARE PIN | OTHER | 111257106 | 01 | KS | MEDICARE PIN | OTHER | KA3249097 | 01 | KS | MEDICARE PIN | OTHER | NA1217018 | 01 | NE | MEDICARE PIN | OTHER | 581760YQPG | 01 | CO | MEDICARE PIN | OTHER | 581760ZLJ3 | 01 | CO | MEDICARE PIN | OTHER | 581760ZNTB | 01 | CO | MEDICARE PIN | OTHER | NA1214119 | 01 | NE | MEDICARE PIN | OTHER | NA1215120 | 01 | NE | MEDICARE PIN | OTHER | 1811287816 | 05 | CO | MEDICAID |