Provider Demographics
NPI:1124021787
Name:FULENWIDER, JULIUS TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:JULIUS
Middle Name:TIMOTHY
Last Name:FULENWIDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JULIUS
Other - Middle Name:T
Other - Last Name:FULENWIDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:770-219-8440
Practice Address - Street 1:1075 JESSE JEWELL PKWY NE
Practice Address - Street 2:STE B
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3814
Practice Address - Country:US
Practice Address - Phone:770-536-5733
Practice Address - Fax:770-534-2114
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0171812086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00199086CMedicaid
GA$$$$$$$$$DMedicare PIN
GAD29510Medicare UPIN