Provider Demographics
NPI:1780728246
Name:DAVID M TULLY SMITH M D A MEDICAL CORPORATION
Entity type:Organization
Organization Name:DAVID M TULLY SMITH M D A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:TULLY-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-544-2632
Mailing Address - Street 1:PO BOX 3137
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94927-3137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 D ST
Practice Address - Street 2:SUITE 111
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3707
Practice Address - Country:US
Practice Address - Phone:415-453-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-17
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30229207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ30674ZMedicare ID - Type UnspecifiedGROUP NUMBER