Provider Demographics
NPI:1982676656
Name:FULTON, ZACHARY J (MD)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:J
Last Name:FULTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 S. HENNEPIN AVE.
Mailing Address - Street 2:KSB MEDICAL GROUP
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021
Mailing Address - Country:US
Mailing Address - Phone:815-285-8520
Mailing Address - Fax:815-285-8903
Practice Address - Street 1:1405 E 12TH ST STE 200
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-9011
Practice Address - Country:US
Practice Address - Phone:815-539-1710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111932207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111932Medicaid
IL036111932Medicaid
ILF400251646Medicare UPIN
I24047Medicare UPIN