Provider Demographics
NPI:1164636619
Name:FULTON, ROBERT W (PT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:FULTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N59W26370 INDIAN HEAD DR
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-4008
Mailing Address - Country:US
Mailing Address - Phone:262-538-0894
Mailing Address - Fax:
Practice Address - Street 1:1640 EAST SUMNER STREET
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027
Practice Address - Country:US
Practice Address - Phone:262-670-4314
Practice Address - Fax:262-670-4301
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1209-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36103300Medicaid