Provider Demographics
NPI:1073518999
Name:ULLOM-MINNICH, MARLA R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARLA
Middle Name:R
Last Name:ULLOM-MINNICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 EAST PACK
Mailing Address - Street 2:
Mailing Address - City:MOUNDRIDGE
Mailing Address - State:KS
Mailing Address - Zip Code:67107-0640
Mailing Address - Country:US
Mailing Address - Phone:620-345-6322
Mailing Address - Fax:620-345-3038
Practice Address - Street 1:200 EAST PACK
Practice Address - Street 2:
Practice Address - City:MOUNDRIDGE
Practice Address - State:KS
Practice Address - Zip Code:67107
Practice Address - Country:US
Practice Address - Phone:620-345-6322
Practice Address - Fax:620-345-3038
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0424208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS02668OtherPREFERRED HEALTH SYSTEMS
KS460686OtherCHILDRENS MERCY FAMILY
KS049108OtherBLUE CROSS/BLUE SHIELD
KS049108OtherBLUE CROSS/BLUE SHIELD
KS02668OtherPREFERRED HEALTH SYSTEMS