Provider Demographics
NPI:1326017013
Name:FUGATE, CARL LEE (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:LEE
Last Name:FUGATE
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:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:KS
Mailing Address - Zip Code:67420-0587
Mailing Address - Country:US
Mailing Address - Phone:785-738-2246
Mailing Address - Fax:785-738-4303
Practice Address - Street 1:1005 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:KS
Practice Address - Zip Code:67420-1215
Practice Address - Country:US
Practice Address - Phone:785-738-2246
Practice Address - Fax:785-738-4303
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS21034207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100205430AMedicaid
KS100205430AMedicaid
021340Medicare ID - Type Unspecified