MEDICARE: PONOS CARE ILLINOIS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1902778293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PONOS CARE ILLINOIS, PLLC

Provider Business Mailing Address
First Line	:	1538 W JACKSON BLVD STE 200
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-5304
Country	:	US
Telephone Number	:	312-610-1000
Fax Number	:	872-351-9638

Provider Business Practice Location Address
First Line	:	1538 W JACKSON BLVD STE 200
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-5304
Country	:	US
Telephone Number	:	312-610-1000
Fax Number	:	872-351-9638

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GILBERTO BULTRON
Credential	:	MD
Telephone Number	:	818-856-6696

Provider Enumeration Date	:	09/18/2025
Last Update Date	:	03/11/2026

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