Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 19010 | KY |
N | 207P00000X | Emergency Physician | ME58598 | FL |
Y | 208D00000X | General Practice Physician | 19010 | KY |
NPI | 1013961986 |
---|---|
Provider Name | Dr. Elzer T. Fuller JR. |
First Address | London, KY 40741-9024 |
Second Address | London, KY 40741-9024 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/05/2006 |
Last Update Date | 13/01/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C71904 | (02) |