Provider Demographics
NPI:1881702322
Name:PULLUKAT, SIMON J (MD)
Entity type:Individual
Prefix:DR
First Name:SIMON
Middle Name:J
Last Name:PULLUKAT
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 1:1075 N EDGAR RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-9584
Mailing Address - Country:US
Mailing Address - Phone:248-563-3848
Mailing Address - Fax:
Practice Address - Street 1:35 SOUTH JOHNSON SUITE 2-D
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341
Practice Address - Country:US
Practice Address - Phone:268-338-0860
Practice Address - Fax:268-338-6013
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035015207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI210999610Medicaid
06302079081Medicare ID - Type Unspecified
MI210999610Medicaid