MEDICARE: ZACHARY J FULTON M.D.

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	207Q00000X	Family Medicine Physician	036111932	IL
2	208M00000X	Hospitalist Physician	036111932	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982676656
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ZACHARY J FULTON M.D.

Provider Business Mailing Address
First Line	:	102 S. HENNEPIN AVE.
Second Line	:	KSB MEDICAL GROUP
City	:	DIXON
State	:	IL
Zip	:	61021
Country	:	US
Telephone Number	:	815-285-8520
Fax Number	:	815-285-8903

Provider Business Practice Location Address
First Line	:	1405 E 12TH ST STE 200
Second Line	:
City	:	MENDOTA
State	:	IL
Zip	:	61342-9011
Country	:	US
Telephone Number	:	815-539-1710
Fax Number	:

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

Provider Enumeration Date	:	02/06/2006
Last Update Date	:	06/29/2022

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