Basic Information
| Provider Information | |||||||||
| NPI: | 1942372396 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULCHER | ||||||||
| FirstName: | LUTHER | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23996 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012066100 | ||||||||
| FaxNumber: | 6012066052 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 MARSHALL ST | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392021651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013522273 | ||||||||
| FaxNumber: | 6013534414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 02/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 05923 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00115674 | 05 | MS | MEDICAID |