Provider Demographics
NPI:1952309114
Name:PULLIN, CLAYTON LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:LOUIS
Last Name:PULLIN
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 680819
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78268-0819
Mailing Address - Country:US
Mailing Address - Phone:210-680-9393
Mailing Address - Fax:210-681-7906
Practice Address - Street 1:7913 BANDERA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78250-6511
Practice Address - Country:US
Practice Address - Phone:210-680-9393
Practice Address - Fax:210-681-7906
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8726207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080187389OtherMEDICARE RAILROAD
TX0076EGOtherBCBS
TX0088MCOtherBCBS GROUP ID
TXJ8726OtherSTATE LICENSE
TXJ8726OtherSTATE LICENSE
TXG47269Medicare UPIN