Provider Demographics
NPI:1194725416
Name:GULLOTTA, DANIEL A (PT,MA)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:A
Last Name:GULLOTTA
Suffix:
Gender:M
Credentials:PT,MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211A MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-2119
Mailing Address - Country:US
Mailing Address - Phone:406-883-8101
Mailing Address - Fax:406-883-8102
Practice Address - Street 1:211A MAIN ST
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-2119
Practice Address - Country:US
Practice Address - Phone:406-883-8101
Practice Address - Fax:406-883-8102
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT741PT208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT062065OtherPPT BC/BS
MT650018165OtherRAILROAD MEDICARE
MT0342244Medicaid
MT061605OtherLPT BCBS
MT0348556Medicaid
MT0342244Medicaid
MT0342244Medicaid