Healthcare Provider Details

I. General information

NPI: 1962409169
Provider Name (Legal Business Name): MARK A FULTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 08/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 S HICKORY ST
MELBOURNE FL
32901-3221
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-3420
  • Fax: 321-434-3423
Mailing address:
  • Phone: 321-434-1981
  • Fax: 321-951-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberME105861
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: