Provider Demographics
NPI:1033591821
Name:TULLY, KEITH L (OD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:L
Last Name:TULLY
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:810 W OCEAN BLVD
Mailing Address - Street 2:SUITE C2
Mailing Address - City:LOS FRESNOS
Mailing Address - State:TX
Mailing Address - Zip Code:78566-3600
Mailing Address - Country:US
Mailing Address - Phone:956-233-5252
Mailing Address - Fax:956-233-6430
Practice Address - Street 1:810 W OCEAN BLVD
Practice Address - Street 2:SUITE C2
Practice Address - City:LOS FRESNOS
Practice Address - State:TX
Practice Address - Zip Code:78566-3600
Practice Address - Country:US
Practice Address - Phone:956-233-5252
Practice Address - Fax:956-233-6430
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX8732T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist