Provider Demographics
NPI:1235141425
Name:TULLUS, MARIANNE W C (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIANNE
Middle Name:W C
Last Name:TULLUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARIANNE
Other - Middle Name:W C
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1200 HENLEY LN
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:FL
Mailing Address - Zip Code:32531-2702
Mailing Address - Country:US
Mailing Address - Phone:850-537-9312
Mailing Address - Fax:850-537-9319
Practice Address - Street 1:1200 HENLEY LN
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:FL
Practice Address - Zip Code:32531-2702
Practice Address - Country:US
Practice Address - Phone:850-537-9312
Practice Address - Fax:850-537-9319
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 95968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276927100Medicaid
FL276927100Medicaid
FLAG972ZMedicare PIN