Provider Demographics
NPI:1205898103
Name:PULLIAM, THOMAS JACKSON (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JACKSON
Last Name:PULLIAM
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 1:5200 W NOB HILL BLVD APT 353
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3668
Mailing Address - Country:US
Mailing Address - Phone:910-638-4239
Mailing Address - Fax:
Practice Address - Street 1:6101 SUMMITVIEW AVE STE 200
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3028
Practice Address - Country:US
Practice Address - Phone:509-902-8857
Practice Address - Fax:509-902-8855
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60730018207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1689283285OtherEMPLOYER NPI: DIRECT IMAGING, PC
WA426319OtherEMPLOYER L&I NO.: DIRECT IMAGING, PC
G9016479OtherEMPLOYER GROUP MEDICARE NO.: DIRECT IMAGING, PC
G9016479OtherEMPLOYER GROUP MEDICARE NO.: DIRECT IMAGING, PC