Healthcare Provider Details

I. General information

NPI: 1912080193
Provider Name (Legal Business Name): CHARLES A FULTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 BROOKSIDE DR
KINGSPORT TN
37660-4627
US

IV. Provider business mailing address

PO BOX 5789
JOHNSON CITY TN
37602-5789
US

V. Phone/Fax

Practice location:
  • Phone: 423-857-7870
  • Fax: 423-857-7872
Mailing address:
  • Phone: 423-915-1126
  • Fax: 423-915-0635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number18954
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: