Provider Demographics
NPI:1689874968
Name:PULLEN, SAMUEL JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JOSEPH
Last Name:PULLEN
Suffix:
Gender:M
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 KIMEL PARK DR STE 200
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6185
Practice Address - Country:US
Practice Address - Phone:336-718-7250
Practice Address - Fax:336-718-7260
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN512412084P0800X
NC2020-003562084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1689874968Medicaid
ID1689874968Medicaid