Provider Demographics
NPI:1700848074
Name:FULTON, MARK J (EDD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:FULTON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 E ELIZABETH AVE
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-6505
Mailing Address - Country:US
Mailing Address - Phone:610-867-4333
Mailing Address - Fax:
Practice Address - Street 1:35 E ELIZABETH AVE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-6505
Practice Address - Country:US
Practice Address - Phone:610-867-4333
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002565L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01555701OtherBLUE CROSS
PA105653OtherBLUE SHIELD
PA105653OtherBLUE SHIELD