Provider Demographics
NPI:1649276981
Name:KULLMAN, FREDERICK M (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:M
Last Name:KULLMAN
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 1:433 SAINT MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7601
Mailing Address - Country:US
Mailing Address - Phone:505-988-1232
Mailing Address - Fax:
Practice Address - Street 1:433 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7601
Practice Address - Country:US
Practice Address - Phone:505-988-1232
Practice Address - Fax:505-984-1603
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM78-202174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
202015408OtherPRESBYTERIAN HEALTH PLAN
NMNM011553OtherBCBS NM
1699938OtherUHC
10003854OtherLOVELACE HEALTH PLAN
NM13672Medicaid
PROVP13502OtherMOLINA
NM44396Medicaid
1699938OtherUHC
NM13672Medicaid