Provider Demographics
NPI:1396835997
Name:FULTS, DANIEL W III (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:W
Last Name:FULTS
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:PO BOX 413030
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3050
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:801-585-3655
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0100
Practice Address - Country:US
Practice Address - Phone:801-581-6908
Practice Address - Fax:801-581-4385
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT175971-1205207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1396835997Medicaid
UT000001851Medicare PIN