Provider Demographics
NPI:1851581052
Name:KENNETH FULTS
Entity Type:Organization
Organization Name:KENNETH FULTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:FULTS
Authorized Official - Suffix:II
Authorized Official - Credentials:DO
Authorized Official - Phone:713-981-1522
Mailing Address - Street 1:223 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-4224
Mailing Address - Country:US
Mailing Address - Phone:903-526-5000
Mailing Address - Fax:903-526-5006
Practice Address - Street 1:11600 JONES RD
Practice Address - Street 2:SUITE108-5
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-5929
Practice Address - Country:US
Practice Address - Phone:713-981-1522
Practice Address - Fax:713-981-9038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD5384208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88W050Medicare PIN