Provider Demographics
NPI:1407991011
Name:FULKERSON, RONALD L (MD PSC)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:L
Last Name:FULKERSON
Suffix:
Gender:M
Credentials:MD PSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391
Mailing Address - Country:US
Mailing Address - Phone:859-744-8003
Mailing Address - Fax:859-744-2286
Practice Address - Street 1:1300 W LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391
Practice Address - Country:US
Practice Address - Phone:859-744-8003
Practice Address - Fax:859-744-2286
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18417208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64184179Medicaid
KY65914350Medicaid
KY65914350Medicaid