Provider Demographics
NPI:1659381531
Name:FULBRIGHT, THOMAS D (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
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:PO BOX 9434
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-9434
Mailing Address - Country:US
Mailing Address - Phone:417-885-3888
Mailing Address - Fax:417-881-7638
Practice Address - Street 1:2900 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-3634
Practice Address - Country:US
Practice Address - Phone:417-885-3888
Practice Address - Fax:417-881-7268
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075293207T00000X
MO2013029759207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC48943Medicare UPIN