Provider Demographics
NPI:1124099866
Name:FULCHER, JOHN HAMPTON (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:HAMPTON
Last Name:FULCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6303
Mailing Address - Fax:
Practice Address - Street 1:1210 W FARIS RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4444
Practice Address - Country:US
Practice Address - Phone:864-295-4410
Practice Address - Fax:864-269-1386
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC121642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC121647Medicaid
SCP00813604OtherRAILROAD MEDICARE
SC121647Medicaid
SCD057101226Medicare ID - Type Unspecified
SCD0571068141Medicare PIN