Provider Demographics
NPI:1871883066
Name:TULLY, LAURA JILL (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:JILL
Last Name:TULLY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JILL
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD
Mailing Address - Street 2:BUILDING B, 3RD FLOOR
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:31 S STANFIELD RD STE 304
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2334
Practice Address - Country:US
Practice Address - Phone:937-440-7872
Practice Address - Fax:937-440-7874
Is Sole Proprietor?:No
Enumeration Date:2011-04-09
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7611207Y00000X
KYC3349207Y00000X
GA207Y00000X
OH35.132034207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology