Provider Demographics
NPI:1356335772
Name:TULLY, JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:TULLY
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:PO BOX 12740
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-2740
Mailing Address - Country:US
Mailing Address - Phone:562-809-3527
Mailing Address - Fax:
Practice Address - Street 1:111 DALLAS ST
Practice Address - Street 2:EMERGENCY ROOM
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-1201
Practice Address - Country:US
Practice Address - Phone:210-614-0180
Practice Address - Fax:210-615-7170
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9524207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168435901Medicaid
TX8M8132OtherBCBS
TX168435902Medicaid
TX8L17430Medicare PIN
TX168435902Medicaid
TX168435901Medicaid