Provider Demographics
NPI:1245528389
Name:FULLEN, RYAN TYLER (OD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:TYLER
Last Name:FULLEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:8096 RIVERS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9235
Mailing Address - Country:US
Mailing Address - Phone:843-818-2020
Mailing Address - Fax:843-818-2379
Practice Address - Street 1:1774 PAXVILLE HWY
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-5071
Practice Address - Country:US
Practice Address - Phone:803-435-2494
Practice Address - Fax:803-435-8765
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1659152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist