Provider Demographics
NPI:1093734469
Name:FULFORD, MICHAEL D (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:FULFORD
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 1:304 LAURENS ST NW
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-3997
Mailing Address - Country:US
Mailing Address - Phone:803-649-9561
Mailing Address - Fax:803-649-2664
Practice Address - Street 1:304 LAURENS ST NW
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-3997
Practice Address - Country:US
Practice Address - Phone:803-649-9561
Practice Address - Fax:803-649-2664
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0517152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0596560001OtherDMERC NUMBER
SC410044189OtherRR MEDICARE
SCDA9643Medicaid
SCT250179184Medicare UPIN