Provider Demographics
NPI:1386802387
Name:FULKERSON, DANIEL H (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:H
Last Name:FULKERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-3245
Mailing Address - Country:US
Mailing Address - Phone:547-647-1840
Mailing Address - Fax:
Practice Address - Street 1:100 NAVARRE PL STE 6600
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1173
Practice Address - Country:US
Practice Address - Phone:574-647-8800
Practice Address - Fax:574-647-8896
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068116A207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200983330Medicaid
IN327270009OtherMEDICARE PTAN
IN000000666210OtherANTHEM BLUE CROSS AND BLUE SHIELD