1083668800 NPI number — KENNETH GUY FULP D.O.

Table of content: KENNETH GUY FULP D.O. (NPI 1083668800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083668800 NPI number — KENNETH GUY FULP D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULP
Provider First Name:
KENNETH
Provider Middle Name:
GUY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083668800
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8405 MYSTIC NIGHT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89143-1358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-755-6709
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6900 NORTH DURANGO DR
Provider Second Line Business Practice Location Address:
CENTENNIAL HILLS HOSPITAL
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89149-4409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-835-9700
Provider Business Practice Location Address Fax Number:
702-835-9700
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  DO1370 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 579328 . This is a "ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM / MEDICAID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1083668800 . This is a "MEDICAID" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: P00990158 . This is a "RAILROAD CARRIER MEDICARE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 1770556037 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1083668800 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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