Provider Demographics
NPI:1013961986
Name:FULLER, ELZER T JR (MD)
Entity type:Individual
Prefix:DR
First Name:ELZER
Middle Name:T
Last Name:FULLER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 LAUREL COVE RD
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-9024
Mailing Address - Country:US
Mailing Address - Phone:606-843-2548
Mailing Address - Fax:859-873-0115
Practice Address - Street 1:969 LAUREL COVE RD
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-9024
Practice Address - Country:US
Practice Address - Phone:606-843-2548
Practice Address - Fax:859-873-0115
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19010208D00000X, 207P00000X
FLME58598207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C71904Medicare UPIN