Individual
DR. MARK AVERY FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
36745 AIKEN RD, BAYFIELD, WI 54814-4579
(715) 779-3707
(715) 779-3362
Mailing address
638 LAKE AVE, IRONWOOD, MI 49938-1424
(906) 364-7105
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
1901-320
WI
208M00000X
Hospitalist Physician
4301093004
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3536500
—
WI
Enumeration date
06/28/2006
Last updated
06/21/2022
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