Provider Demographics
NPI:1679062632
Name:FULLER, CHAD (MD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:
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 1:1250 PEACH ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2871
Mailing Address - Country:US
Mailing Address - Phone:805-543-4043
Mailing Address - Fax:805-543-7640
Practice Address - Street 1:1250 PEACH ST STE A
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2871
Practice Address - Country:US
Practice Address - Phone:805-543-4043
Practice Address - Fax:805-543-7640
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-05
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA174124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine