Provider Demographics
NPI:1295768463
Name:TULLOUS, MICAM W (MD)
Entity type:Individual
Prefix:DR
First Name:MICAM
Middle Name:W
Last Name:TULLOUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:315 N SAN SABA
Mailing Address - Street 2:SUITE 1210
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3154
Mailing Address - Country:US
Mailing Address - Phone:210-354-0877
Mailing Address - Fax:210-354-0880
Practice Address - Street 1:315 N SAN SABA
Practice Address - Street 2:SUITE 1210
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3154
Practice Address - Country:US
Practice Address - Phone:210-354-0877
Practice Address - Fax:210-354-0880
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG8470207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3339002OtherBC/BS
TX124306501Medicaid
TX12430695-06Medicaid
TX3339002OtherBC/BS
TX124306501Medicaid
TN80882FMedicare ID - Type Unspecified