Provider Demographics
NPI:1063595593
Name:HULTQUIST, MARC ALAN (DO)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:ALAN
Last Name:HULTQUIST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:12205 COUNTY LINE RD STE C
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-7720
Mailing Address - Country:US
Mailing Address - Phone:256-258-8319
Mailing Address - Fax:256-489-4070
Practice Address - Street 1:12205 COUNTY LINE RD STE C
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-7720
Practice Address - Country:US
Practice Address - Phone:256-258-8319
Practice Address - Fax:256-489-4070
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA3331208000000X
AL30422080P0006X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty