Provider Demographics
NPI:1730573254
Name:FULLER, GRIFFIN LOWE (MD)
Entity type:Individual
Prefix:
First Name:GRIFFIN
Middle Name:LOWE
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 E RUNDBERG LN STE B1
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-4860
Mailing Address - Country:US
Mailing Address - Phone:512-978-9600
Mailing Address - Fax:512-901-9771
Practice Address - Street 1:825 E RUNDBERG LN STE B1
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-4860
Practice Address - Country:US
Practice Address - Phone:512-978-9600
Practice Address - Fax:512-901-9771
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS3661207Q00000X, 207R00000X
IN11018498A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine