Provider Demographics
NPI:1154356731
Name:GULLO, SIBEL S (MD)
Entity type:Individual
Prefix:
First Name:SIBEL
Middle Name:S
Last Name:GULLO
Suffix:
Gender:F
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:PO BOX 910670
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40591-0670
Mailing Address - Country:US
Mailing Address - Phone:859-971-4685
Mailing Address - Fax:859-971-4602
Practice Address - Street 1:100 PROVIDENCE WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-6031
Practice Address - Country:US
Practice Address - Phone:859-260-5370
Practice Address - Fax:859-260-5379
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33508208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64353089Medicaid
KY00574020Medicare PIN