Provider Demographics
NPI:1356437958
Name:DULL, MARK A (DC,DABCO,DACBSP)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:DULL
Suffix:
Gender:M
Credentials:DC,DABCO,DACBSP
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 130
Mailing Address - Street 2:
Mailing Address - City:TWIN LAKES
Mailing Address - State:WI
Mailing Address - Zip Code:53181
Mailing Address - Country:US
Mailing Address - Phone:262-877-2196
Mailing Address - Fax:262-877-2204
Practice Address - Street 1:237 E. MAIN ST
Practice Address - Street 2:
Practice Address - City:TWIN LAKES
Practice Address - State:WI
Practice Address - Zip Code:53181
Practice Address - Country:US
Practice Address - Phone:262-877-2196
Practice Address - Fax:262-877-2204
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2331-012111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38931200Medicaid