Provider Demographics
NPI:1891920344
Name:GULLOTTI, MICHAEL J
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:GULLOTTI
Suffix:
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 1:639 W GLENSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-2101
Mailing Address - Country:US
Mailing Address - Phone:215-694-3923
Mailing Address - Fax:
Practice Address - Street 1:301 N 4TH ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18102-3007
Practice Address - Country:US
Practice Address - Phone:610-437-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1018830390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program