# FULLER DERMATOLOGY LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1083159529
- **Authorized official:** DR. BRUCE W. FULLER MD (OWNER)
- **Authorized official phone:** (727) 347-7524

## Contact information

- **Practice address:** 1609 PASADENA AVE S STE 4C, SOUTH PASADENA, FL 33707
- **Practice address phone:** (727) 347-7524
- **Mailing address:** 1609 PASADENA AVE S STE 4C, SOUTH PASADENA, FL 33707-4564

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM2500X | Medical Specialty Clinic/Center | ME99153 | FL | Yes |

## Other

- **Enumeration date:** 12/19/2016
- **Last updated:** 08/29/2018