Individual
DR. KEITH LYLE FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
2214 GATEWAY DR, SUITE C, OPELIKA, AL 36801-1500
(334) 741-0075
(334) 741-4075
Mailing address
2214 GATEWAY DR, SUITE C, OPELIKA, AL 36801-1500
(334) 741-0075
(334) 741-4075
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
DO350
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000026574
—
AL
01
—
51026574
BLUE CROSS BLUE SHIELD
AL
01
—
DO350
MEDICAL LICENSE
AL
Enumeration date
06/21/2006
Last updated
03/07/2023
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