Provider Demographics
NPI:1114986031
Name:PULIDO, FRED T JR (MD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:T
Last Name:PULIDO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 VIRGINIA ST E
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2908
Mailing Address - Country:US
Mailing Address - Phone:304-345-5466
Mailing Address - Fax:304-345-5472
Practice Address - Street 1:1213 VIRGINIA ST E
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2908
Practice Address - Country:US
Practice Address - Phone:304-345-5466
Practice Address - Fax:304-345-5472
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10371208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0114257000Medicaid
WV3572755200OtherU.S. DEPT. OF LABOR
WV0359506OtherCIGNA
WV225394OtherMAMSI
WV0359506OtherCIGNA
WV0114257000Medicaid