MEDICARE: ELBERT FULGRAM JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	25298725	TX

General Provider Information

NPI Number	:	1194298141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELBERT FULGRAM JR.

Provider Business Mailing Address
First Line	:	8134 MONTERRA RANCH DR APT 3622
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-6231
Country	:	US
Telephone Number	:	480-930-0459
Fax Number	:

Provider Business Practice Location Address
First Line	:	8134 MONTERRA RANCH DR APT 3622
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-6231
Country	:	US
Telephone Number	:	480-930-0459
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2019
Last Update Date	:	01/02/2019

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