Provider Demographics
NPI:1598717985
Name:TULLIS, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:TULLIS
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 1:3875 E OVERLAND RD STE 2D
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9005
Mailing Address - Country:US
Mailing Address - Phone:208-600-1550
Mailing Address - Fax:208-600-1551
Practice Address - Street 1:3875 E OVERLAND RD STE 2D
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9005
Practice Address - Country:US
Practice Address - Phone:208-600-1550
Practice Address - Fax:208-600-1551
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-79392086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288349Medicaid
ID000010028313OtherBLUE SHIELD
ID805714900Medicaid
IDJ3938OtherBLUE CROSS
ID770002414OtherRRMC
OR288349Medicaid
IDJ3938OtherBLUE CROSS
ID770002414OtherRRMC