Provider Demographics
NPI:1679543102
Name:KELLUM, RONALD FULTON (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:FULTON
Last Name:KELLUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:149 DRINKWATER RD
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-1658
Mailing Address - Country:US
Mailing Address - Phone:228-467-8676
Mailing Address - Fax:228-467-8674
Practice Address - Street 1:4433 LEISURE TIME
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3259
Practice Address - Country:US
Practice Address - Phone:228-586-9229
Practice Address - Fax:228-586-9230
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS19011207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS19011OtherMISSISSIPPI LICENSE