Provider Demographics
NPI:1043229446
Name:FULTON, AMY (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:FULTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5615 NW 86TH ST
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1738
Practice Address - Country:US
Practice Address - Phone:515-643-6000
Practice Address - Fax:515-643-6001
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1188094Medicaid
IA1188094Medicaid
IAI9757Medicare ID - Type Unspecified