MEDICARE: DR. KATHLEEN MARY DULLY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	G72961	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00G729610	OTHER	CA	MEDI-CAL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487655536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHLEEN MARY DULLY M.D.

Provider Business Mailing Address
First Line	:	3020 CHILDRENS WAY
Second Line	:	MC 5014
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4223
Country	:	US
Telephone Number	:	858-966-5980
Fax Number	:	858-312-5360

Provider Business Practice Location Address
First Line	:	3020 CHILDRENS WAY
Second Line	:	MC 5014
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4223
Country	:	US
Telephone Number	:	858-966-5980
Fax Number	:	858-312-5360

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	09/21/2009

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