Provider Demographics
NPI:1295701670
Name:FULTON, MICHAEL N (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:N
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 1:3127 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
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME036059207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL79517Medicare PIN