Healthcare Provider Details

I. General information

NPI: 1184050601
Provider Name (Legal Business Name): BRANDON ELLIS TULLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 08/03/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 CANYONS RESORT DRIVE
PARK CITY UT
84098-6546
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 435-645-4130
  • Fax:
Mailing address:
  • Phone: 435-645-4130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number5980963-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: