Individual
JEFFERY FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
4864 JACKSON ST, DEPARTMENT OF EMERGENCY MEDICAL SERVICES, MONROE, LA 71202-6400
(318) 675-7737
(318) 675-5666
Mailing address
1501 KINGS HWY, MANAGED CARE, SHREVEPORT, LA 71103
(318) 675-7737
(318) 675-5666
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
018474
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1357723
—
LA
Enumeration date
08/10/2006
Last updated
07/08/2007
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