Provider Demographics
NPI:1851547301
Name:FULTON, ROBERT ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALLEN
Last Name:FULTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 W CHICKASHA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2504
Mailing Address - Country:US
Mailing Address - Phone:405-224-3937
Mailing Address - Fax:405-224-4375
Practice Address - Street 1:402 W CHICKASHA AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2504
Practice Address - Country:US
Practice Address - Phone:405-224-3937
Practice Address - Fax:405-224-4375
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-15
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2559152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKAAA2511OtherMEDICARE INDIVIDUAL PTAN
OKOKAAA2512OtherMEDICARE GROUP PTAN
20-5009490OtherFEDERAL TAX ID