Provider Demographics
NPI:1730221490
Name:FULLER, TRACY ANN (MD)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ANN
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:1500 CITYWEST BLVD STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-2549
Practice Address - Country:US
Practice Address - Phone:972-233-1999
Practice Address - Fax:972-233-3666
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5171207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194331802Medicaid
TX8AK832OtherBLUE CROSS BLUE SHIELD OF TEXAS
TX194331803Medicaid
TX194331801Medicaid
TXTXB117116Medicare PIN
TX194331803Medicaid