Provider Demographics
NPI:1679568794
Name:FULSOM, DONALD RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:RAY
Last Name:FULSOM
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 1:401 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8213
Mailing Address - Country:US
Mailing Address - Phone:903-593-6550
Mailing Address - Fax:903-593-6554
Practice Address - Street 1:401 E FRONT ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8213
Practice Address - Country:US
Practice Address - Phone:903-593-6550
Practice Address - Fax:903-593-6554
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL60472084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX15804250Medicaid
TX00903HMedicare ID - Type Unspecified
TXH85841Medicare UPIN