Provider Demographics
NPI:1902005689
Name:LORA FULP EFAW MD PC
Entity Type:Organization
Organization Name:LORA FULP EFAW MD PC
Other - Org Name:CENTER FOR HEALING AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORA
Authorized Official - Middle Name:
Authorized Official - Last Name:EFAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-388-9393
Mailing Address - Street 1:1807 OLD OCILLA RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1617
Mailing Address - Country:US
Mailing Address - Phone:229-388-9393
Mailing Address - Fax:229-388-9855
Practice Address - Street 1:1807 OLD OCILLA RD
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1617
Practice Address - Country:US
Practice Address - Phone:229-388-9393
Practice Address - Fax:229-388-9855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036727207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG54477Medicare UPIN