Provider Demographics
NPI:1922239110
Name:MICHAEL N FULTON
Entity Type:Organization
Organization Name:MICHAEL N FULTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:N
Authorized Official - Last Name:FULTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-258-9502
Mailing Address - Street 1:3127 W INTERNATIONAL SPEEDWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32124-1070
Mailing Address - Country:US
Mailing Address - Phone:386-258-9502
Mailing Address - Fax:386-239-9781
Practice Address - Street 1:3127 W INTERNATIONAL SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32124-1070
Practice Address - Country:US
Practice Address - Phone:386-258-9502
Practice Address - Fax:386-239-9781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty