Healthcare Provider Details

I. General information

NPI: 1821593039
Provider Name (Legal Business Name): MERCY FULTANG MD, DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S OSTEOPATHY AVE
KIRKSVILLE MO
63501-6401
US

IV. Provider business mailing address

2908 WOODWIND CT
KIRKSVILLE MO
63501-5724
US

V. Phone/Fax

Practice location:
  • Phone: 660-785-1000
  • Fax:
Mailing address:
  • Phone: 713-261-6410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberS3520
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2016025512
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: