Healthcare Provider Details

I. General information

NPI: 1265674485
Provider Name (Legal Business Name): KARLIS ULLIS, M.D., A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 03/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WILSHIRE BLVD SUITE 425
SANTA MONICA CA
90401-1872
US

IV. Provider business mailing address

900 WILSHIRE BLVD SUITE 425
SANTA MONICA CA
90401-1872
US

V. Phone/Fax

Practice location:
  • Phone: 310-452-1990
  • Fax: 310-452-5134
Mailing address:
  • Phone: 310-452-1990
  • Fax: 310-452-5134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License NumberG20989
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberG20989
License Number StateCA

VIII. Authorized Official

Name: DR. KARLIS CONRAD ULLIS
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 310-452-1990