Provider Demographics
NPI:1649268533
Name:FULLER, DOUGLAS CONRAD (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:CONRAD
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 CARSWELL DR. BLDG 340
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191
Mailing Address - Country:US
Mailing Address - Phone:702-653-3431
Mailing Address - Fax:702-653-3591
Practice Address - Street 1:4311 CARSWELL AVE BLDG 340
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191-7069
Practice Address - Country:US
Practice Address - Phone:702-653-3431
Practice Address - Fax:702-653-3591
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV189722083A0100X, 2083X0100X
UT358526-12052083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine