Provider Demographics
NPI:1255315479
Name:PULASKI, EDWIN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:THOMAS
Last Name:PULASKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 WILLIAMS DRIVE
Mailing Address - Street 2:STE 200
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4623
Mailing Address - Country:US
Mailing Address - Phone:703-641-9133
Mailing Address - Fax:703-280-5098
Practice Address - Street 1:10215 FERNWOOD RD
Practice Address - Street 2:STE 50
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817
Practice Address - Country:US
Practice Address - Phone:301-564-1053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC96014462085B0100X, 2085R0202X, 2085R0204X
MDD00150472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
78270OtherMEDCOST
WV2004964000Medicaid
5612683OtherAETNA
VA7200099Medicaid
NC891115HMedicaid
1115HOtherBCBS
28411OtherPARTNERS
300130864OtherRR MEDICARE
SCQ01446Medicaid
28411OtherPARTNERS
SCQ01446Medicaid
003367W85Medicare PIN