Provider Demographics
NPI:1528237690
Name:B. JEFFREY PULK, P.C.
Entity type:Organization
Organization Name:B. JEFFREY PULK, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:PULK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:231-946-0333
Mailing Address - Street 1:515 S UNION ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3246
Mailing Address - Country:US
Mailing Address - Phone:231-946-0333
Mailing Address - Fax:231-946-1665
Practice Address - Street 1:515 S UNION ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3246
Practice Address - Country:US
Practice Address - Phone:231-946-0333
Practice Address - Fax:231-946-1665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004124152WC0802X, 152WS0006X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4351130Medicaid
MIU92569Medicare UPIN
MI4351130Medicaid