Individual
LARRY CHAD FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
STUDENT
Contact information
Practice address
1600 SW ARCHER RD, GAINESVILLE, FL 32610-2360
(352) 265-0291
Mailing address
PO BOX 100374, GAINESVILLE, FL 32610-0374
(352) 265-0291
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
0102209072
VA
2085R0202X
Diagnostic Radiology Physician
1322733
GA
2085R0202X
Diagnostic Radiology Physician
Primary
OS17722
FL
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
110846200
—
FL
Enumeration date
04/01/2016
Last updated
10/01/2025
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