Healthcare Provider Details

I. General information

NPI: 1841266350
Provider Name (Legal Business Name): JACQUELINE FULTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE CARTER FULTON

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 DIVISION ST
BALTIMORE MD
21217-3121
US

IV. Provider business mailing address

6264 SETON HILLS LN
GWYNN OAK MD
21207-6080
US

V. Phone/Fax

Practice location:
  • Phone: 410-383-8300
  • Fax:
Mailing address:
  • Phone: 410-298-1320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0023806
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: