Healthcare Provider Details

I. General information

NPI: 1336128230
Provider Name (Legal Business Name): TONY TULLOT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 KINGSLEY AVE
ORANGE PARK FL
32073-5148
US

IV. Provider business mailing address

7111 FAIRWAY DR SUITE 400
PALM BEACH GARDENS FL
33418-4204
US

V. Phone/Fax

Practice location:
  • Phone: 904-276-8517
  • Fax: 904-276-8611
Mailing address:
  • Phone: 561-712-6265
  • Fax: 561-712-7349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberME43280
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME0043280
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: