Provider Demographics
NPI:1609119304
Name:KULLUKIAN, DANIEL (MD, SA-C)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:KULLUKIAN
Suffix:
Gender:M
Credentials:MD, SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4626 E SHEENA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-5524
Mailing Address - Country:US
Mailing Address - Phone:602-295-8370
Mailing Address - Fax:
Practice Address - Street 1:4626 E. SHEENA DR.
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032
Practice Address - Country:US
Practice Address - Phone:602-295-8370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17193246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1609119304Medicaid