Basic Information
Provider Information | |||||||||
NPI: | 1568428795 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STEPHEN M PULLEN PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11808-1 SAN JOSE BLVD | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 32223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042622249 | ||||||||
FaxNumber: | 9042688283 | ||||||||
Practice Location | |||||||||
Address1: | 11808-1 SAN JOSE BLVD | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 32223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042622249 | ||||||||
FaxNumber: | 9042688283 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2006 | ||||||||
LastUpdateDate: | 12/11/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PULLEN | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | MCAFEE | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER OPTOMETRIST | ||||||||
AuthorizedOfficialTelephone: | 9042622249 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | OD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 74964 | 01 | FL | BCBS | OTHER |