Provider Demographics
NPI:1134102528
Name:POOTHULLIL, JOHN MATHEW (MD,FRCP,FAAP)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MATHEW
Last Name:POOTHULLIL
Suffix:
Gender:M
Credentials:MD,FRCP,FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 OAK DR S
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5676
Mailing Address - Country:US
Mailing Address - Phone:979-297-8006
Mailing Address - Fax:979-297-5919
Practice Address - Street 1:201 OAK DR S
Practice Address - Street 2:SUITE 106
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5676
Practice Address - Country:US
Practice Address - Phone:979-297-8006
Practice Address - Fax:979-297-5919
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6880207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX02914600-01OtherCIGNA
TX10020011OtherAMERIKIDS
TX02914600-14OtherCIGNA SELECT
TX02914600-13OtherCIGNA HMO
TX2225592OtherBCBS BLUE LINK
TX02914600-13OtherCIGNA HMO
TX2225592OtherBCBS BLUE LINK