Individual
DR. JOHN M FULTZ II
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1314 CHURCH ST, EVANSTON, IL 60201-3508
(773) 275-6349
(773) 275-6385
Mailing address
1314 CHURCH ST, EVANSTON, IL 60201-3508
(773) 275-6349
(773) 275-6385
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
036042979
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036042979
—
IL
01
—
14D0876728
CLIA ID MEDICARE
IL
01
—
21608069
BCBS INS ID
IL
01
—
363179161
TAX ID
IL
01
—
792111199
RAILROAD MEDICARE ID
IL
Enumeration date
09/27/2006
Last updated
01/06/2017
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