Healthcare Provider Details

I. General information

NPI: 1083835623
Provider Name (Legal Business Name): STEPHEN BRADFORD HULSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9898 GENESEE AVE
LA JOLLA CA
92037-1205
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 858-626-7275
  • Fax:
Mailing address:
  • Phone: 858-626-7275
  • Fax: 858-626-4085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA87249
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA87249
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: