Active NPI
Michael J Fullerton, O.D.
- Optometrist
- Pryor, OK
National Provider Identifier
1215071949
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 877
- Practice address
- 202 S Adair St
Pryor, OK 74361-5202 - Phone
- (918) 825-0055
- Fax
- (918) 824-2000
- NPI assigned
- Feb 16, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 877 | OK | Primary |
Addresses
Primary practice location
202 S Adair St
Pryor, OK 74361-5202
Mailing address
PO Box 1400
Pryor, OK 74362-1400
Phone (918) 825-0055
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 100764830A | Medicaid | OK |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 877 | OK | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1171584000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1237939200000",
"number": "1215071949",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 1400",
"city": "PRYOR",
"state": "OK",
"postal_code": "743621400",
"telephone_number": "918-825-0055",
"fax_number": "918-824-2000"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "202 S ADAIR ST",
"city": "PRYOR",
"state": "OK",
"postal_code": "743615202",
"telephone_number": "918-825-0055",
"fax_number": "918-824-2000"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FULLERTON",
"first_name": "MICHAEL",
"middle_name": "J",
"credential": "O.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-02-16",
"last_updated": "2009-03-25",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "OK",
"license": "877",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "100764830A",
"state": "OK"
}
],
"endpoints": [],
"other_names": []
}Other providers in Pryor, OK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.