Individual
RICHARD E FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
17780 VERSAILLES CT, BROOKFIELD, WI 53045-5026
(262) 389-1375
Mailing address
17780 VERSAILLES CT, BROOKFIELD, WI 53045-5026
(262) 389-1375
Taxonomy
Speciality
Code
Description
License number
State
207QA0505X
Adult Medicine Physician
Primary
32988-020
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1306841002
BCBS
WI
05
—
208000000X
—
WI
05
—
31875900
—
WI
Enumeration date
06/17/2005
Last updated
06/11/2021
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