Provider Demographics
NPI:1710274410
Name:FULTZ, JULIE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:MARIE
Last Name:FULTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:MARIE
Other - Last Name:MAIRS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8710 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2724
Mailing Address - Country:US
Mailing Address - Phone:314-961-3570
Mailing Address - Fax:
Practice Address - Street 1:8710 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2724
Practice Address - Country:US
Practice Address - Phone:314-961-3570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.060358207P00000X
MO2013021211207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine