Healthcare Provider Details

I. General information

NPI: 1346219557
Provider Name (Legal Business Name): JUANCARLOS BULLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HARTLE CT
NAPA CA
94559-4078
US

IV. Provider business mailing address

1141 PEAR TREE LN STE 100
NAPA CA
94558-6485
US

V. Phone/Fax

Practice location:
  • Phone: 707-254-1775
  • Fax: 707-254-1779
Mailing address:
  • Phone: 707-254-1770
  • Fax: 707-254-1779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA66601
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA66601
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: