Provider Demographics
NPI:1275525693
Name:FULCHIERO, RANDALL M (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:M
Last Name:FULCHIERO
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 1:1520 S MAIN ST
Mailing Address - Street 2:# 2
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2698
Mailing Address - Country:US
Mailing Address - Phone:937-461-5815
Mailing Address - Fax:937-461-2896
Practice Address - Street 1:1520 S MAIN ST
Practice Address - Street 2:# 2
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2698
Practice Address - Country:US
Practice Address - Phone:937-461-5815
Practice Address - Fax:937-461-2896
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35068723207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0168992Medicaid
OH4820105OtherUNITED HEALTHCARE
OH000000012028OtherANTHEM BCBS
OH0786591Medicare ID - Type UnspecifiedMEDICARE
OH0168992Medicaid