Healthcare Provider Details

I. General information

NPI: 1285608554
Provider Name (Legal Business Name): CARL E FULWILER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 W MAIN ST
NORTHBOROUGH MA
01532-3810
US

IV. Provider business mailing address

PO BOX 62 TURNPIKE STATION
SHREWSBURY MA
01545-0062
US

V. Phone/Fax

Practice location:
  • Phone: 774-329-9228
  • Fax: 508-856-8700
Mailing address:
  • Phone: 508-334-8815
  • Fax: 508-334-5374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number80208
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: