Healthcare Provider Details

I. General information

NPI: 1609119304
Provider Name (Legal Business Name): DANIEL KULLUKIAN M.D., SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4626 E. SHEENA DR.
PHOENIX AZ
85032
US

IV. Provider business mailing address

4626 E SHEENA DR
PHOENIX AZ
85032-5524
US

V. Phone/Fax

Practice location:
  • Phone: 602-295-8370
  • Fax:
Mailing address:
  • Phone: 602-295-8370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number17193
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: