Provider Demographics
NPI:1699831909
Name:DULL, ETHAN A (DC)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:A
Last Name:DULL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12711 W MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-1831
Mailing Address - Country:US
Mailing Address - Phone:262-542-4700
Mailing Address - Fax:262-542-7499
Practice Address - Street 1:2343 SILVERNAIL RD
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5402
Practice Address - Country:US
Practice Address - Phone:262-542-4700
Practice Address - Fax:262-542-7499
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3571111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38922600Medicaid
WIU78547Medicare UPIN
WI000735165Medicare ID - Type Unspecified