Provider Demographics
NPI:1043315468
Name:FULK, BILLY RAY (MD)
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:RAY
Last Name:FULK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16731 MCGREGOR BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-3843
Mailing Address - Country:US
Mailing Address - Phone:239-437-2121
Mailing Address - Fax:
Practice Address - Street 1:16731 MCGREGOR BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3843
Practice Address - Country:US
Practice Address - Phone:239-437-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63287207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC38116Medicare UPIN