Provider Demographics
NPI:1801853296
Name:PULLEN, STEPHEN M (OD)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:M
Last Name:PULLEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11808-1 SAN JOSE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223
Mailing Address - Country:US
Mailing Address - Phone:904-262-2249
Mailing Address - Fax:904-268-8283
Practice Address - Street 1:11808-1 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223
Practice Address - Country:US
Practice Address - Phone:904-262-2249
Practice Address - Fax:904-268-8283
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3511152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL68102OtherBCBS
FLU65140Medicare UPIN
FL68102OtherBCBS
FL0555130001Medicare NSC