Provider Demographics
NPI:1982678231
Name:GULLY, KYLE L (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:L
Last Name:GULLY
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:1302 N PACIFIC ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:TX
Practice Address - Zip Code:75773-1022
Practice Address - Country:US
Practice Address - Phone:903-569-5383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4176207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111823401Medicaid
TX8531J5Medicare ID - Type Unspecified
TX111823401Medicaid
TX080165962Medicare PIN