Provider Demographics
NPI:1962409169
Name:FULTON, MARK A (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:FULTON
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-1981
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1251 S HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3221
Practice Address - Country:US
Practice Address - Phone:321-434-3420
Practice Address - Fax:321-434-3423
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105861207T00000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001679400Medicaid
FLCS864XOtherMEDICARE
FLCS864YOtherMEDICARE
FLCS864XOtherMEDICARE
OH4982480003Medicare NSC
OHFU0847984Medicare PIN
OHFU0847981Medicare PIN
FLCS864ZMedicare PIN
FL001679400Medicaid
OH140005622Medicare PIN
FLCS864ZMedicare PIN
OH4182352004OtherCIGNA HEALTHCARE PIN
OH310874776034OtherCARESOURCE PIN
FL001679400Medicaid
OH140005622Medicare PIN