NPIMap

Individual provider Active NPI

Kristopher Vaughn Pullam, MD

  • Family Medicine Physician
  • Fenton, MO
National Provider Identifier
1679067276
Registry record updated Jun 8, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
2021019546 Issued in MO
Practice address
1203 Smizer Mill Rd Ste 105
Fenton, MO 63026-3483
Phone
(636) 717-1350
NPI assigned
Jun 18, 2018
Last updated
Jun 8, 2021By the provider in NPPES
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Jun 8, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 2021019546 MO Primary

Addresses

Primary practice location

1203 Smizer Mill Rd Ste 105
Fenton, MO 63026-3483

Mailing address

1203 Smizer Mill Rd Ste 105
Fenton, MO 63026-3483
Phone (636) 717-1350

Other practice location 1

621 S New Ballas Rd
Saint Louis, MO 63141-8232
Phone (314) 251-8888

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20211020002439 MO Practitioner - Family Practice 3678822269 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2018
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Mercy Clinic East CommunitiesGroup PAC ID 7214827922, 573 clinicians

Practice addresses (Care Compare)

1203 Smizer Mill Rd
Suite 105
Fenton, MO 63026-3483
Phone (636) 717-1350

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
2021019546MOMDFamily Medicine Physician

Interoperability endpoints

  • Direct secure messaging: kpullam986370@directc.mercy.net

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1529280000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1623110400000",
    "number": "1679067276",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1203 SMIZER MILL RD STE 105",
            "city": "FENTON",
            "state": "MO",
            "postal_code": "630263483",
            "telephone_number": "636-717-1350",
            "fax_number": "314-251-8889"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1203 SMIZER MILL RD STE 105",
            "city": "FENTON",
            "state": "MO",
            "postal_code": "630263483",
            "telephone_number": "636-717-1350"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "621 S New Ballas Rd",
            "address_purpose": "LOCATION",
            "city": "Saint Louis",
            "state": "MO",
            "postal_code": "631418232",
            "country_code": "US",
            "telephone_number": "314-251-8888",
            "fax_number": "314-251-8889",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PULLAM",
        "first_name": "KRISTOPHER",
        "middle_name": "VAUGHN",
        "name_prefix": "Mr.",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2018-06-18",
        "last_updated": "2021-06-08",
        "certification_date": "2021-06-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MO",
            "license": "2021019546",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fenton, MO

Sources for this page

Verify at the official NPI Registry.