Provider Demographics
NPI:1609814441
Name:FULTON, MATTHEW BERNARD (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:BERNARD
Last Name:FULTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13306
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24032-3306
Mailing Address - Country:US
Mailing Address - Phone:540-345-0289
Mailing Address - Fax:540-345-9569
Practice Address - Street 1:5115 BERNARD DR STE 201
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-4367
Practice Address - Country:US
Practice Address - Phone:540-345-0289
Practice Address - Fax:540-345-9569
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201846207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology