Provider Demographics
NPI:1871682237
Name:CARULLI, NICHOLAS F (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:F
Last Name:CARULLI
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 8945
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-8945
Mailing Address - Country:US
Mailing Address - Phone:360-694-7565
Mailing Address - Fax:360-906-0871
Practice Address - Street 1:304 N LIESER RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-2115
Practice Address - Country:US
Practice Address - Phone:360-694-7565
Practice Address - Fax:360-906-0871
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037171207R00000X
ORMD16072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1107689Medicaid
WAG8857768Medicare PIN
WA1107689Medicaid