Provider Demographics
NPI:1215970819
Name:TULLEY, CHARLES A III (MD)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:A
Last Name:TULLEY
Suffix:III
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 1:1101 S EUSTIS ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-5558
Mailing Address - Country:US
Mailing Address - Phone:352-589-4111
Mailing Address - Fax:352-589-4245
Practice Address - Street 1:1101 S EUSTIS ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-5558
Practice Address - Country:US
Practice Address - Phone:352-589-4111
Practice Address - Fax:352-589-4245
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36920207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35187OtherBCBS
FL35187VMedicare ID - Type Unspecified
FL35187OtherBCBS