Provider Demographics
NPI:1093975203
Name:ULLOM, MATHEW DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:DAVID
Last Name:ULLOM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 STOVER ST
Mailing Address - Street 2:BLDG. F
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4641
Mailing Address - Country:US
Mailing Address - Phone:970-491-9191
Mailing Address - Fax:970-223-2293
Practice Address - Street 1:2550 STOVER ST
Practice Address - Street 2:BLDG. F
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4641
Practice Address - Country:US
Practice Address - Phone:970-491-9191
Practice Address - Fax:970-223-2293
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6192111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation