Provider Demographics
NPI:1013942663
Name:GULOTTA, JAY P (DC)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:P
Last Name:GULOTTA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 PARK TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-5944
Mailing Address - Country:US
Mailing Address - Phone:815-877-5014
Mailing Address - Fax:
Practice Address - Street 1:1116 PARK TERRACE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-5944
Practice Address - Country:US
Practice Address - Phone:815-877-5014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL255440Medicare ID - Type Unspecified