Provider Demographics
NPI:1922176635
Name:FULNECKY, ERIC J (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:J
Last Name:FULNECKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1900 S NATIONAL AVE
Practice Address - Street 2:SUITE 2955
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2265
Practice Address - Country:US
Practice Address - Phone:417-820-3905
Practice Address - Fax:417-820-3528
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2004006990207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209153907Medicaid
P00207385OtherRAILROAD MEDICARE
431560263OtherTRICARE
MO919223268Medicare PIN
MO209153907Medicaid