Provider Demographics
NPI:1407977630
Name:FULKS, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FULKS
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 1:17580 CLINTON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-9633
Mailing Address - Country:US
Mailing Address - Phone:860-562-1153
Mailing Address - Fax:
Practice Address - Street 1:M352 MASS MUTUAL
Practice Address - Street 2:1295 STATE STREET
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01111-0001
Practice Address - Country:US
Practice Address - Phone:860-562-1153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57117207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine