Provider Demographics
NPI:1497723258
Name:TULYASATHIEN, XAMNAN (MD)
Entity Type:Individual
Prefix:DR
First Name:XAMNAN
Middle Name:
Last Name:TULYASATHIEN
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 1:215 E 1ST ST
Mailing Address - Street 2:STE 305
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3166
Mailing Address - Country:US
Mailing Address - Phone:815-285-5800
Mailing Address - Fax:815-285-5691
Practice Address - Street 1:215 E 1ST ST
Practice Address - Street 2:STE 305
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3166
Practice Address - Country:US
Practice Address - Phone:815-285-5800
Practice Address - Fax:815-285-5691
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL50806Medicare PIN
C38890Medicare UPIN