Provider Demographics
NPI:1144237751
Name:FULKS, KENNETH DWAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DWAYNE
Last Name:FULKS
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 1:1601 HATCHER LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4826
Mailing Address - Country:US
Mailing Address - Phone:931-381-2802
Mailing Address - Fax:931-388-0719
Practice Address - Street 1:1601 HATCHER LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4826
Practice Address - Country:US
Practice Address - Phone:931-381-2802
Practice Address - Fax:931-388-0719
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0195952086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3059467Medicaid
TN3059467Medicaid
TN3059467Medicare ID - Type Unspecified