Provider Demographics
NPI:1083668800
Name:FULP, KENNETH GUY (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:GUY
Last Name:FULP
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8131 S MEMORIAL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-4348
Mailing Address - Country:US
Mailing Address - Phone:918-200-9944
Mailing Address - Fax:877-616-3089
Practice Address - Street 1:8131 S MEMORIAL DR STE 100
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4348
Practice Address - Country:US
Practice Address - Phone:918-200-9944
Practice Address - Fax:877-616-3089
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO1370207L00000X
OK5873207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ579328OtherARIZONA HEALTH CARE COST CONTAINMENT SYSTEM / MEDICAID
WA1083668800OtherMEDICAID
NVP00990158OtherRAILROAD CARRIER MEDICARE
UT1770556037Medicaid
NV1083668800Medicaid
NV1083668800Medicaid