Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 21688 | WV |
N | 207Q00000X | Family Doctor | 21688 | WV |
N | 207Q00000X | Family Doctor | TP578 | KY |
N | 207QS0010X | Family Doctor - Sports Medicine | 21688 | WV |
NPI | 1285713156 |
---|---|
Provider Name | Dr. Jeremy D Fuller |
First Address | Huntington, WV 25701-3804 |
Second Address | Huntington, WV 25701-3804 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2006 |
Last Update Date | 13/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1285713156 | (05) | WV |
2783519 | (05) | OH |
7100048840 | (05) | KY |
BF9296509 | DEA NUMBER (01) | WV |