Provider Demographics
NPI:1669451316
Name:FULP, CHARLES J JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:FULP
Suffix:JR
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 1:600 PARKWAY NORTH
Mailing Address - Street 2:CANCER TREATMENT CENTERS FOR AMERICA
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265
Mailing Address - Country:US
Mailing Address - Phone:404-250-6797
Mailing Address - Fax:404-256-3271
Practice Address - Street 1:600 PARKWAY NORTH
Practice Address - Street 2:CANCER TREATMENT CENTERS OF AMERICA
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265
Practice Address - Country:US
Practice Address - Phone:770-400-6000
Practice Address - Fax:404-256-3271
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031917174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000428491AMedicaid
GAD27178Medicare UPIN
GA30CDBNQMedicare ID - Type Unspecified