Healthcare Provider Details

I. General information

NPI: 1043473226
Provider Name (Legal Business Name): JOHN WATHAN GULLETT II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

563 WESSEL DR
FAIRFIELD OH
45014-3668
US

IV. Provider business mailing address

5535 FAIR LN SUITE C
CINCINNATI OH
45227-3434
US

V. Phone/Fax

Practice location:
  • Phone: 513-858-6500
  • Fax: 513-858-2777
Mailing address:
  • Phone: 513-221-5274
  • Fax: 513-961-5100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number097924
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: