Provider Demographics
NPI:1194298141
Name:FULGRAM, ELBERT JR
Entity type:Individual
Prefix:
First Name:ELBERT
Middle Name:
Last Name:FULGRAM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8134 MONTERRA RANCH DR APT 3622
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-6231
Mailing Address - Country:US
Mailing Address - Phone:480-930-0459
Mailing Address - Fax:
Practice Address - Street 1:8134 MONTERRA RANCH DR APT 3622
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-6231
Practice Address - Country:US
Practice Address - Phone:480-930-0459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25298725172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver