1629231832 NPI number — DR. MATHEW J PULICKEN MD

Table of content: DR. MATHEW J PULICKEN MD (NPI 1629231832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629231832 NPI number — DR. MATHEW J PULICKEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PULICKEN
Provider First Name:
MATHEW
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1629231832
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1155 MILL ST # M14
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89502-1576
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-982-5262
Provider Business Mailing Address Fax Number:
775-982-5496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 PRINGLE WAY STE 401
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89502-1476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-982-5000
Provider Business Practice Location Address Fax Number:
775-982-2973
Provider Enumeration Date:
07/08/2008

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: 2084N0400X , with the licence number:  MD13907 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 984370 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 23127 . This is a "NEVADA LIC" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 1102512 . This is a "CAQH" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".