1770585994 NPI number — RAYMOND R FULP III DO

Table of content: RAYMOND R FULP III DO (NPI 1770585994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770585994 NPI number — RAYMOND R FULP III DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULP
Provider First Name:
RAYMOND
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FULP
Provider Other First Name:
REY TREY
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
III
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1770585994
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
721 LINDBERG AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78501-2913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-668-7746
Provider Business Mailing Address Fax Number:
956-668-8338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
721 LINDBERG AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78501-2913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-668-7746
Provider Business Practice Location Address Fax Number:
956-668-8338
Provider Enumeration Date:
06/01/2005

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: 207X00000X , with the licence number:  J7963 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201350018 . This is a "TAX ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 129886107 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5197053 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 142047100 . This is a "VALLEY HEALTH PLANS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8H9770 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 200046413 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 123586 . This is a "CHIPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 046982702 . This is a "CSHCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 4103818 . This is a "BLUELINK" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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