Basic Information
| Provider Information | |||||||||
| NPI: | 1982676656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULTON | ||||||||
| FirstName: | ZACHARY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 102 S. HENNEPIN AVE. | ||||||||
| Address2: | KSB MEDICAL GROUP | ||||||||
| City: | DIXON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152858520 | ||||||||
| FaxNumber: | 8152858903 | ||||||||
| Practice Location | |||||||||
| Address1: | 1405 E 12TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | MENDOTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613429011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155391710 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036111932 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 036111932 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 036111932 | 05 | IL | MEDICAID |