Provider Demographics
NPI:1548218118
Name:FULP, SAM R (MD)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:R
Last Name:FULP
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:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28070-0497
Mailing Address - Country:US
Mailing Address - Phone:704-377-4009
Mailing Address - Fax:
Practice Address - Street 1:1340 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:SUITE 301
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5580
Practice Address - Country:US
Practice Address - Phone:704-377-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32500207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD29513Medicare UPIN
2147833KMedicare ID - Type Unspecified