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General NPI Number Information
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NPI Number | 1861644379
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Entity Type | Organization
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Legal Business Name | PAUL FULGHUM OD PA
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Dates
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Enumeration Date | 10/15/2008
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Last Update Date | 11/03/2010
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Provider Practice Location Address
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Address Line | 4225 LAKESIDE DR
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City | JACKSONVILLE
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State | FL
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Zip | 32210-3305
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Country | US
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Telephone | 904-387-5704
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Fax |
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Provider Business Mailing Address
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Address Line | 4225 LAKESIDE DR
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City | JACKSONVILLE
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State | FL
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Zip | 32210-3305
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Country | US
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Telephone | 904-387-5704
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | PAUL FULGHUM
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Credential | OPTOMETRIST
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Telephone | 904-387-5704
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC1834
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License Number State | FL
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