Healthcare Provider Details

I. General information

NPI: 1306814298
Provider Name (Legal Business Name): KRISTINE P PULTORAK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 11/17/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 E 1ST ST
DIXON IL
61021
US

IV. Provider business mailing address

403 E 1ST ST
DIXON IL
61021-3116
US

V. Phone/Fax

Practice location:
  • Phone: 815-288-5561
  • Fax: 815-285-5859
Mailing address:
  • Phone: 815-288-5561
  • Fax: 815-285-5859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-092252
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036.092252
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: