Healthcare Provider Details

I. General information

NPI: 1053486571
Provider Name (Legal Business Name): LORI J. FULTON, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1963 W MCDOWELL RD
JACKSON MS
39204-4217
US

IV. Provider business mailing address

1963 W MCDOWELL RD
JACKSON MS
39204-4217
US

V. Phone/Fax

Practice location:
  • Phone: 601-372-3634
  • Fax: 601-372-7361
Mailing address:
  • Phone: 601-372-3634
  • Fax: 601-372-7361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LORI J. FULTON
Title or Position: OWNER
Credential: MD
Phone: 601-372-3632