Provider Demographics
NPI:1700843646
Name:FULTON, BRIAN THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:THOMAS
Last Name:FULTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 10TH ST SE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LE MARS
Mailing Address - State:IA
Mailing Address - Zip Code:51031-2550
Mailing Address - Country:US
Mailing Address - Phone:712-546-4624
Mailing Address - Fax:
Practice Address - Street 1:180 10TH ST SE
Practice Address - Street 2:SUITE 201
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031-2550
Practice Address - Country:US
Practice Address - Phone:712-546-4624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA017202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA03064Medicare UPIN
28812Medicare ID - Type Unspecified