Provider Demographics
NPI:1184658114
Name:FULMER, DANIEL C (DPM)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:C
Last Name:FULMER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 E MILLENNIUM PL
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-6514
Mailing Address - Country:US
Mailing Address - Phone:479-582-1199
Mailing Address - Fax:479-582-1194
Practice Address - Street 1:2828 E MILLENNIUM PL
Practice Address - Street 2:SUITE 2
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6514
Practice Address - Country:US
Practice Address - Phone:479-582-1199
Practice Address - Fax:479-582-1194
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR155213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR021200117OtherQUALCHOICE
AR5X002OtherBLUE SHIELD
AR148310717Medicaid
OK200021680AMedicaid
AR155OtherBLUE CROSS
AR155OtherBLUE CROSS
AR148310717Medicaid
OK200021680AMedicaid