Provider Demographics
NPI:1609837541
Name:FULTON, DONALD SAMUEL (OD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:SAMUEL
Last Name:FULTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 MONROE TPKE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-2338
Mailing Address - Country:US
Mailing Address - Phone:203-261-5783
Mailing Address - Fax:203-268-7036
Practice Address - Street 1:471 MONROE TPKE
Practice Address - Street 2:SUITE 200
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2338
Practice Address - Country:US
Practice Address - Phone:203-261-5783
Practice Address - Fax:203-268-7036
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT765152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT11871OtherBLOCK
CT4024196Medicaid
CT5031124OtherCIGNA
CT97773-365OtherUS HEALTHCARE
CT0V2239OtherHEALTHNET
CTP378118OtherOXFORD
CT97773-365OtherAETNA
CT662967OtherCONNECTICARE
CT090000765CT02OtherANTHEM
CT090000765CT01OtherANTHEM
CT117607OtherEYEMED
CT97773-365OtherAETNA
CT97773-365OtherAETNA
CT11871OtherBLOCK
CT5031124OtherCIGNA