Healthcare Provider Details

I. General information

NPI: 1134935711
Provider Name (Legal Business Name): ETHAN WARNER PULLIAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 W 86TH ST
INDIANAPOLIS IN
46260-1902
US

IV. Provider business mailing address

340 W 10TH ST
INDIANAPOLIS IN
46202-3082
US

V. Phone/Fax

Practice location:
  • Phone: 317-800-4940
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number11024925A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: