Provider Demographics
NPI:1346224532
Name:FULLIN, KEVIN J (MD FACC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:FULLIN
Suffix:
Gender:M
Credentials:MD FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6308 8TH AVE
Mailing Address - Street 2:SUITE 3060
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5082
Mailing Address - Country:US
Mailing Address - Phone:262-656-3650
Mailing Address - Fax:262-656-3671
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:SUITE 3060
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5082
Practice Address - Country:US
Practice Address - Phone:262-656-3650
Practice Address - Fax:262-656-3671
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27973207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30742900Medicaid
WI1346224532Medicaid
WI1346224532Medicaid
B52941Medicare UPIN