Individual
DR. MAYNARD DARVY FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
150 S ROADRUNNER PKWY, LAS CRUCES, NM 88011-7044
(505) 556-8600
(505) 556-8700
Mailing address
PO BOX 911230, DALLAS, TX 75391-1230
(972) 997-8000
(972) 437-9605
Taxonomy
Speciality
Code
Description
License number
State
207RX0202X
Medical Oncology Physician
Primary
97239
NM
207RX0202X
Medical Oncology Physician
G4000
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000S2815
—
NM
05
—
126330301
—
TX
05
—
126330307
—
TX
05
—
140998901
—
TX
01
—
48753001
CSHCN
—
01
—
8R1442
BLUE CROSS OF TEXAS
TX
Enumeration date
06/12/2006
Last updated
05/02/2008
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