Healthcare Provider Details

I. General information

NPI: 1194708495
Provider Name (Legal Business Name): BRENT N FULTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 09/20/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

873 HULL RD UNIT 12
ORMOND BEACH FL
32174
US

IV. Provider business mailing address

873 HULL RD UNIT 12
ORMOND BEACH FL
32174
US

V. Phone/Fax

Practice location:
  • Phone: 386-267-2965
  • Fax: 386-603-6007
Mailing address:
  • Phone: 386-267-2965
  • Fax: 386-603-6007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME94759
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME94759
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: