Provider Demographics
NPI:1851804991
Name:FULMORE, CLIFFORD (DPT)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:
Last Name:FULMORE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 E 7TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-5903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:651 E 7TH ST FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-5903
Practice Address - Country:US
Practice Address - Phone:646-418-9499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-12
Last Update Date:2017-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041817208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PENDINGOtherPENDING