Provider Demographics
NPI:1851369664
Name:TULLY, THOMAS W JR
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:TULLY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N BONITA AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-3623
Mailing Address - Country:US
Mailing Address - Phone:850-747-6000
Mailing Address - Fax:
Practice Address - Street 1:615 N BONITA AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3623
Practice Address - Country:US
Practice Address - Phone:850-747-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033876207P00000X
FL102657207P00000X
WI42410-20207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8195596Medicaid
M18541OtherREGENCE BLUE SHIELD RIDER
930103921OtherRAILROAD MEDICARE
M18541OtherREGENCE BLUE SHIELD RIDER
WA8195596Medicaid