Provider Demographics
NPI:1174569107
Name:FULLER, GREGORY W (DO)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:W
Last Name:FULLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-1851
Mailing Address - Country:US
Mailing Address - Phone:517-784-6663
Mailing Address - Fax:517-787-7976
Practice Address - Street 1:1006 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-1851
Practice Address - Country:US
Practice Address - Phone:517-784-6663
Practice Address - Fax:517-787-7976
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI012543207PE0004X
FLOS5478207Q00000X
MI5101012543207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114545400Medicaid
MIGF012543OtherBLUE SHIELD
MI114545400Medicaid
MIM60660267Medicare PIN