=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073752176
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DONALD S FULTON OD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2009
-----------------------------------------------------
Last Update Date | 11/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 471 MONROE TPKE SUITE 200
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06468-2338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-261-5783
-----------------------------------------------------
Fax | 203-268-7036
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 471 MONROE TPKE SUITE 200
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06468-2338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-261-5783
-----------------------------------------------------
Fax | 203-268-7036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | DR. DONALD S FULTON
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 203-261-5783
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 765
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------