Provider Demographics
NPI:1285606020
Name:GULLIC, PHILLIP THOMAS (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:THOMAS
Last Name:GULLIC
Suffix:
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 1:2519 COLLEGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6135
Mailing Address - Country:US
Mailing Address - Phone:501-327-6547
Mailing Address - Fax:501-327-9715
Practice Address - Street 1:2180 ADA AVENUE
Practice Address - Street 2:SUITE 300
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-7203
Practice Address - Country:US
Practice Address - Phone:501-327-6547
Practice Address - Fax:501-327-9715
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE 1631207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR134193001Medicaid
BG4992372OtherDRUG ENFORCEMENT ADMINIST
AR134193001Medicaid
5K744Medicare ID - Type Unspecified