Healthcare Provider Details

I. General information

NPI: 1679760698
Provider Name (Legal Business Name): ALLAN W. TULLOCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8631 W 3RD ST SUITE #615 E
LOS ANGELES CA
90048-5901
US

IV. Provider business mailing address

1505 S BENTLEY AVE APT 304
LOS ANGELES CA
90025-3317
US

V. Phone/Fax

Practice location:
  • Phone: 310-652-8132
  • Fax: 310-659-3815
Mailing address:
  • Phone: 646-263-5842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number104567
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: