Provider Demographics
NPI:1497822845
Name:FULLER, TIMOTHY LOUIS (DO)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:LOUIS
Last Name:FULLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 15004
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37901
Mailing Address - Country:US
Mailing Address - Phone:865-522-9730
Mailing Address - Fax:865-637-2520
Practice Address - Street 1:428 EAST VANN ROAD
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37743-7202
Practice Address - Country:US
Practice Address - Phone:423-278-1950
Practice Address - Fax:423-278-1973
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN1343208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4121421OtherBCBST
TNTN01Q1OtherJD
TNTN01Q1OtherJD