Provider Demographics
NPI:1255353223
Name:FULTON EYECARE CENTER PLLC
Entity type:Organization
Organization Name:FULTON EYECARE CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:FULTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-224-3937
Mailing Address - Street 1:402 W CHICKASHA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2461
Mailing Address - Country:US
Mailing Address - Phone:405-224-3937
Mailing Address - Fax:405-224-4375
Practice Address - Street 1:402 W CHICKASHA AVE STE 100
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2461
Practice Address - Country:US
Practice Address - Phone:405-224-3937
Practice Address - Fax:405-224-4375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2559152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKAAA2512OtherMEDICARE GROUP PTAN
OK1851547301OtherPERSONAL NPI #
OKOKAAA2511OtherMEDICARE INDIVIDUAL PTAN