Provider Demographics
NPI:1265674485
Name:KARLIS ULLIS, M.D., A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:KARLIS ULLIS, M.D., A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KARLIS
Authorized Official - Middle Name:CONRAD
Authorized Official - Last Name:ULLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-452-1990
Mailing Address - Street 1:900 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 425
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1872
Mailing Address - Country:US
Mailing Address - Phone:310-452-1990
Mailing Address - Fax:310-452-5134
Practice Address - Street 1:900 WILSHIRE BLVD
Practice Address - Street 2:SUITE 425
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1872
Practice Address - Country:US
Practice Address - Phone:310-452-1990
Practice Address - Fax:310-452-5134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-02
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG209892083S0010X, 204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA90674Medicare UPIN