Healthcare Provider Details

I. General information

NPI: 1962559302
Provider Name (Legal Business Name): BHARATHI PULLA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6125 GREEN BAY RD
KENOSHA WI
53142-2928
US

IV. Provider business mailing address

6125 GREEN BAY RD
KENOSHA WI
53142-2928
US

V. Phone/Fax

Practice location:
  • Phone: 262-564-8636
  • Fax: 262-564-8637
Mailing address:
  • Phone: 262-564-8636
  • Fax: 262-564-8637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number41182
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number41182
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: