Basic Information
| Provider Information | |||||||||
| NPI: | 1801853296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PULLEN | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| 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: | 04/28/2006 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC3511 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 68102 | 01 | FL | BCBS | OTHER |