Healthcare Provider Details

I. General information

NPI: 1992965974
Provider Name (Legal Business Name): MYCHAILO FULMES M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MICHAEL FULMES M.D.

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2647 CONEY ISLAND AVE
BROOKLYN NY
11223-5502
US

IV. Provider business mailing address

3037 30TH ST APT 4F
ASTORIA NY
11102-2242
US

V. Phone/Fax

Practice location:
  • Phone: 718-743-4450
  • Fax: 718-743-4452
Mailing address:
  • Phone: 917-284-7455
  • Fax: 718-743-4452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number250373-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: