Provider Demographics
NPI:1124097191
Name:FULCHER, TODD L (MD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:L
Last Name:FULCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 AMITY LN
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7941
Mailing Address - Country:US
Mailing Address - Phone:601-206-0901
Mailing Address - Fax:888-240-6288
Practice Address - Street 1:MANHATTAN NURSING AND REHABILITATION CENTER
Practice Address - Street 2:4540 MANHATTAN RD
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206
Practice Address - Country:US
Practice Address - Phone:601-206-0901
Practice Address - Fax:888-240-6288
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS12503207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS753068151002OtherTRICARE
MSP00061664OtherRR MEDICARE
MS753068151OtherMS PHYSICIANS CARE NETWOR
MS168390700OtherUS DEPT OF LABOR
MS75306815OtherMS HEALTH PARTNERS
MS753068151OtherUHC
MS00111649Medicaid
MS753068151Other1ST CHOICE
MS4554283OtherAETNA
MS00111649Medicaid
MS080003807Medicare PIN