Provider Demographics
NPI:1164083093
Name:FULTZ, JASON KEITH (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:KEITH
Last Name:FULTZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:551 E SOUTHAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-4236
Mailing Address - Country:US
Mailing Address - Phone:573-884-7733
Mailing Address - Fax:573-882-6228
Practice Address - Street 1:1650 SLAUGHTER RD STE A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-8610
Practice Address - Country:US
Practice Address - Phone:256-325-3646
Practice Address - Fax:256-325-3647
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2022-08-01
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Provider Licenses
StateLicense IDTaxonomies
MO2019022592207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine