Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | MD070596L | PA |
N | 111NI0900X | Internist | MD070596L | PA |
N | 207RC0200X | Critical Care Medicine | MD070596L | PA |
Y | 207RP1001X | Pulmonary Disease | MD070596L | PA |
NPI | 1053714881 |
---|---|
Provider Name | Dr. Mikael Dawit Tulloch-Reid |
First Address | Kingston, KINGSTON KINGSTON 10 |
Second Address | Kingston, KINGSTON KINGSTON 10 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/10/2014 |
Last Update Date | 07/10/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MD070596L | MEDICAL LICENSE (01) | PA |