Provider Demographics
NPI:1548213119
Name:FULBRIGHT, THOMAS WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WAYNE
Last Name:FULBRIGHT
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 1:8901 W 74TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2201
Mailing Address - Country:US
Mailing Address - Phone:913-261-2222
Mailing Address - Fax:913-261-2229
Practice Address - Street 1:8901 W 74TH ST STE 2
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-2201
Practice Address - Country:US
Practice Address - Phone:913-261-2222
Practice Address - Fax:913-261-2229
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008009944207Q00000X, 208M00000X
KS0421422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS19774052OtherBLUE CROSS BLUE SHIELD KC
KS19774052OtherBLUE CROSS BLUE SHIELD KC
MOMA1572001Medicare PIN