Provider Demographics
NPI:1497136501
Name:FULTON, DAVID BRANDON (OTR/L)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:BRANDON
Last Name:FULTON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 LAKELAND BLVD APT 157
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8919
Mailing Address - Country:US
Mailing Address - Phone:601-562-2164
Mailing Address - Fax:
Practice Address - Street 1:5201 LAKELAND BLVD APT 157
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8919
Practice Address - Country:US
Practice Address - Phone:601-562-2164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT3047225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist