MEDICARE: PAUL FULGHUM OD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPC1834	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861644379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAUL FULGHUM OD PA

Provider Business Mailing Address
First Line	:	4225 LAKESIDE DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-3305
Country	:	US
Telephone Number	:	904-387-5704
Fax Number	:

Provider Business Practice Location Address
First Line	:	4225 LAKESIDE DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-3305
Country	:	US
Telephone Number	:	904-387-5704
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PAUL FULGHUM
Credential	:	OPTOMETRIST
Telephone Number	:	904-387-5704

Provider Enumeration Date	:	10/15/2008
Last Update Date	:	11/03/2010

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