Provider Demographics
NPI:1538235502
Name:FULLER, BRIAN J (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:FULLER
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Gender:M
Credentials:MD
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Mailing Address - Street 1:3087 TEJON ST
Mailing Address - Street 2:SPT C
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-3976
Mailing Address - Country:US
Mailing Address - Phone:720-220-7857
Mailing Address - Fax:303-320-2934
Practice Address - Street 1:2373 CENTRAL PARK BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-2300
Practice Address - Country:US
Practice Address - Phone:720-220-7857
Practice Address - Fax:303-287-7357
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2011-08-12
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Provider Licenses
StateLicense IDTaxonomies
CO46857208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03433544Medicaid
COCC4908Medicare PIN