1356335772 NPI number — DR. JOHN TULLY M.D.

Table of content: DR. JOHN TULLY M.D. (NPI 1356335772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356335772 NPI number — DR. JOHN TULLY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TULLY
Provider First Name:
JOHN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356335772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12740
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTMINSTER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92685-2740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-809-3527
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 DALLAS ST
Provider Second Line Business Practice Location Address:
EMERGENCY ROOM
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78205-1201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-614-0180
Provider Business Practice Location Address Fax Number:
210-615-7170
Provider Enumeration Date:
08/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207PE0004X , with the licence number:  L9524 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 168435901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8M8132 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 168435902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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