Provider Demographics
NPI:1336310770
Name:FULGHUM, MARK (MPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FULGHUM
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 PEAK ST
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-3151
Mailing Address - Country:US
Mailing Address - Phone:727-515-3206
Mailing Address - Fax:
Practice Address - Street 1:2960 TAMPA RD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3340
Practice Address - Country:US
Practice Address - Phone:727-786-4009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19278225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist