Provider Demographics
NPI:1245262682
Name:PULLIAM, IAN THOMAS (DO)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:THOMAS
Last Name:PULLIAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3437
Mailing Address - Country:US
Mailing Address - Phone:209-832-8984
Mailing Address - Fax:209-832-8988
Practice Address - Street 1:644 W 12TH ST
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3437
Practice Address - Country:US
Practice Address - Phone:209-832-8984
Practice Address - Fax:209-832-8988
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7496207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F88671Medicare UPIN