Provider Demographics
NPI:1962436121
Name:FULGHUM, PAUL (OD PA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FULGHUM
Suffix:
Gender:M
Credentials:OD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-3305
Mailing Address - Country:US
Mailing Address - Phone:904-387-5704
Mailing Address - Fax:904-387-5751
Practice Address - Street 1:4225 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-3305
Practice Address - Country:US
Practice Address - Phone:904-387-5704
Practice Address - Fax:904-387-5751
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1834152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL086952300Medicaid
FL19827Medicare ID - Type Unspecified
FL086952300Medicaid