Basic Information
| Provider Information | |||||||||
| NPI: | 1124021787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULENWIDER | ||||||||
| FirstName: | JULIUS | ||||||||
| MiddleName: | TIMOTHY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FULENWIDER | ||||||||
| OtherFirstName: | JULIUS | ||||||||
| OtherMiddleName: | T | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 742616 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303742616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702198420 | ||||||||
| FaxNumber: | 7702198440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1075 JESSE JEWELL PKWY NE | ||||||||
| Address2: | STE B | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705365733 | ||||||||
| FaxNumber: | 7705342114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 12/09/2015 | ||||||||
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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 | 2086S0129X | 017181 | GA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | 017181 | GA | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00199086C | 05 | GA | MEDICAID |