Provider Demographics
NPI:1699262386
Name:FULPS FAMILY EYE CARE, LLC
Entity type:Organization
Organization Name:FULPS FAMILY EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CALEN
Authorized Official - Middle Name:N
Authorized Official - Last Name:FULPS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-812-9327
Mailing Address - Street 1:401 W MIAMI ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-4842
Mailing Address - Country:US
Mailing Address - Phone:918-812-9327
Mailing Address - Fax:
Practice Address - Street 1:3300 S ASPEN AVE STE D
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012
Practice Address - Country:US
Practice Address - Phone:918-451-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-18
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2924152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200737030AMedicaid