Provider Demographics
NPI:1871720300
Name:FULLER, PHILLIP TYLER (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:TYLER
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1414 ARLINGTON STREET
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820
Mailing Address - Country:US
Mailing Address - Phone:580-332-0112
Mailing Address - Fax:580-332-1005
Practice Address - Street 1:1414 ARLINGTON STREET
Practice Address - Street 2:SUITE 2300
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820
Practice Address - Country:US
Practice Address - Phone:580-332-0112
Practice Address - Fax:580-332-1005
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2014-06-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK30483208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology