Healthcare Provider Details

I. General information

NPI: 1538265541
Provider Name (Legal Business Name): EDWARD JOHN MCNULTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 CLEMENT ST 111C
SAN FRANCISCO CA
94121-1545
US

IV. Provider business mailing address

80 MANCHESTER ST
SAN FRANCISCO CA
94110-5215
US

V. Phone/Fax

Practice location:
  • Phone: 415-750-2112
  • Fax:
Mailing address:
  • Phone: 415-641-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberA89696
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: