Provider Demographics
NPI:1306814298
Name:PULTORAK, KRISTINE P (DO)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:P
Last Name:PULTORAK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3116
Mailing Address - Country:US
Mailing Address - Phone:815-288-5561
Mailing Address - Fax:815-285-5859
Practice Address - Street 1:403 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-288-5561
Practice Address - Fax:815-285-5859
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-092252207Q00000X
IL036.092252207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092252Medicaid
IL800200006OtherMEDICARE
IL381220005OtherMEDICARE