Provider Demographics
NPI:1831284900
Name:PULLOS, TAKE GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:TAKE
Middle Name:GEORGE
Last Name:PULLOS
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:PO BOX 20970
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7020
Mailing Address - Country:US
Mailing Address - Phone:307-632-1114
Mailing Address - Fax:307-632-9920
Practice Address - Street 1:5201 YELLOWSTONE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4741
Practice Address - Country:US
Practice Address - Phone:307-632-1114
Practice Address - Fax:307-632-9920
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYA73020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY100097800Medicaid
WY1831284900Medicaid
WY302240Medicare ID - Type Unspecified
WY1831284900Medicaid
WYW24201Medicare PIN