Provider Demographics
NPI:1730220815
Name:POOTHULLIL, THOMAS M (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:M
Last Name:POOTHULLIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4714
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-4714
Mailing Address - Country:US
Mailing Address - Phone:228-896-7336
Mailing Address - Fax:228-896-7996
Practice Address - Street 1:2330 E PASS RD
Practice Address - Street 2:SUITE 3
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3817
Practice Address - Country:US
Practice Address - Phone:228-896-7336
Practice Address - Fax:228-896-7996
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07935207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00016357Medicaid
MS00016357Medicaid
MS112945321Medicare ID - Type Unspecified