Provider Demographics
NPI:1215071949
Name:FULLERTON, MICHAEL J (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:FULLERTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1400
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74362-1400
Mailing Address - Country:US
Mailing Address - Phone:918-825-0055
Mailing Address - Fax:918-824-2000
Practice Address - Street 1:202 S ADAIR ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-5202
Practice Address - Country:US
Practice Address - Phone:918-825-0055
Practice Address - Fax:918-824-2000
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK877152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100764830AMedicaid
OK0766210001Medicare NSC
OKT40455Medicare UPIN