Healthcare Provider Details

I. General information

NPI: 1497723258
Provider Name (Legal Business Name): XAMNAN TULYASATHIEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 12/14/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E 1ST ST STE 305
DIXON IL
61021-3166
US

IV. Provider business mailing address

215 E 1ST ST STE 305
DIXON IL
61021-3166
US

V. Phone/Fax

Practice location:
  • Phone: 815-285-5800
  • Fax: 815-285-5691
Mailing address:
  • Phone: 815-285-5800
  • Fax: 815-285-5691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: