Provider Demographics
NPI:1366814113
Name:FULLER ROBERTS OB-GYN AND PRIMARY CARE
Entity type:Organization
Organization Name:FULLER ROBERTS OB-GYN AND PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / M.D.
Authorized Official - Prefix:
Authorized Official - First Name:DUC
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIEU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-572-8921
Mailing Address - Street 1:2212 WILBORN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1630
Mailing Address - Country:US
Mailing Address - Phone:434-572-8921
Mailing Address - Fax:
Practice Address - Street 1:2212 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1630
Practice Address - Country:US
Practice Address - Phone:434-572-8921
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239403207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty