Provider Demographics
NPI:1518086479
Name:FULTZ, JOHN A
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:A
Last Name:FULTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3542 SPRINGWOOD ST
Mailing Address - Street 2:APT. 604
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-1632
Mailing Address - Country:US
Mailing Address - Phone:580-716-1731
Mailing Address - Fax:
Practice Address - Street 1:201 E CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-4311
Practice Address - Country:US
Practice Address - Phone:580-763-0931
Practice Address - Fax:580-763-0934
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator