Provider Demographics
NPI:1053486571
Name:LORI J. FULTON, M.D.
Entity Type:Organization
Organization Name:LORI J. FULTON, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:J
Authorized Official - Last Name:FULTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-372-3632
Mailing Address - Street 1:1963 W MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-4217
Mailing Address - Country:US
Mailing Address - Phone:601-372-3634
Mailing Address - Fax:601-372-7361
Practice Address - Street 1:1963 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-4217
Practice Address - Country:US
Practice Address - Phone:601-372-3634
Practice Address - Fax:601-372-7361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03603Medicare ID - Type Unspecified