Provider Demographics
NPI:1801233135
Name:FULEKI, KEITH STEPHEN (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:STEPHEN
Last Name:FULEKI
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 1:300 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1118
Mailing Address - Country:US
Mailing Address - Phone:585-637-3905
Mailing Address - Fax:585-637-4990
Practice Address - Street 1:301 WEST AVE
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:NY
Practice Address - Zip Code:14411-1522
Practice Address - Country:US
Practice Address - Phone:585-589-5613
Practice Address - Fax:585-637-2375
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY282568207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04358518Medicaid