Provider Demographics
NPI:1083777890
Name:FULTS, JOHN ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:FULTS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 E WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:BROADWELL
Mailing Address - State:IL
Mailing Address - Zip Code:62634-6367
Mailing Address - Country:US
Mailing Address - Phone:217-732-7422
Mailing Address - Fax:
Practice Address - Street 1:1631 E EMPIRE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3531
Practice Address - Country:US
Practice Address - Phone:309-662-4074
Practice Address - Fax:309-662-4074
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46-006841152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL153692Medicare UPIN