Provider Demographics
NPI:1659564326
Name:FULTZ, GEORGE S (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:S
Last Name:FULTZ
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 1:3120 S BUSINESS DR # 291
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-6524
Mailing Address - Country:US
Mailing Address - Phone:920-458-5163
Mailing Address - Fax:
Practice Address - Street 1:316 GEELE AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-5060
Practice Address - Country:US
Practice Address - Phone:920-458-5163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000159412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology