Provider Demographics
NPI:1952630642
Name:STULL, MICHAEL B (IDMT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:B
Last Name:STULL
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 S DALLAS AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-6028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:904 S DALLAS AVE APT 3
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6028
Practice Address - Country:US
Practice Address - Phone:575-784-0287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-09
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians