Provider Demographics
NPI:1902034614
Name:ULLOM, ROBERT LEROY (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEROY
Last Name:ULLOM
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 1:8200 W CENTRAL AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-3661
Mailing Address - Country:US
Mailing Address - Phone:316-721-4544
Mailing Address - Fax:
Practice Address - Street 1:8200 W CENTRAL AVE STE 1
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-3661
Practice Address - Country:US
Practice Address - Phone:316-491-6340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-34369207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine