Provider Demographics
NPI:1750385340
Name:FULTZ, MARVIN CLARK (DO)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:CLARK
Last Name:FULTZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CUT BANK
Mailing Address - State:MT
Mailing Address - Zip Code:59427-3015
Mailing Address - Country:US
Mailing Address - Phone:406-873-5670
Mailing Address - Fax:406-873-2256
Practice Address - Street 1:519 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CUT BANK
Practice Address - State:MT
Practice Address - Zip Code:59427-3015
Practice Address - Country:US
Practice Address - Phone:406-873-5670
Practice Address - Fax:406-873-2256
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8022207Q00000X
WV1440207Q00000X
AK5911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0038726Medicaid
AKMD6852Medicaid
MT0038726Medicaid
AKMD6852Medicaid