Provider Demographics
NPI:1992965974
Name:FULMES, MYCHAILO (MD, PHD)
Entity type:Individual
Prefix:
First Name:MYCHAILO
Middle Name:
Last Name:FULMES
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:FULMES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3037 30TH ST APT 4F
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-2242
Mailing Address - Country:US
Mailing Address - Phone:917-284-7455
Mailing Address - Fax:718-743-4452
Practice Address - Street 1:2647 CONEY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-5502
Practice Address - Country:US
Practice Address - Phone:718-743-4450
Practice Address - Fax:718-743-4452
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY250373-1208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery