1801853296 NPI number — MR. STEPHEN M PULLEN OD

Table of content: MR. STEPHEN M PULLEN OD (NPI 1801853296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801853296 NPI number — MR. STEPHEN M PULLEN OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PULLEN
Provider First Name:
STEPHEN
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1801853296
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11808-1 SAN JOSE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-262-2249
Provider Business Mailing Address Fax Number:
904-268-8283

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 A1A N STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PONTE VEDRA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32082-6626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-280-9000
Provider Business Practice Location Address Fax Number:
904-280-4448
Provider Enumeration Date:
04/28/2006

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: 152W00000X , with the licence number:  OPC3511 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 68102 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 117785800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com