Provider Demographics
NPI:1922006436
Name:TULL, GEORGE W JR (OD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:W
Last Name:TULL
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2232 N 7TH ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-7459
Mailing Address - Country:US
Mailing Address - Phone:970-242-4909
Mailing Address - Fax:970-243-7171
Practice Address - Street 1:2232 N 7TH ST
Practice Address - Street 2:SUITE 10
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-7459
Practice Address - Country:US
Practice Address - Phone:970-242-4909
Practice Address - Fax:970-243-7171
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2010-10-18
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-20
Provider Licenses
StateLicense IDTaxonomies
COCO1426152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08014268Medicaid
CO0729640001OtherPALMETTO
CO08014268Medicaid
C811416Medicare PIN