Healthcare Provider Details

I. General information

NPI: 1932215944
Provider Name (Legal Business Name): MARINA BULATOV M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 WEBSTER ST STE 200
OAKLAND CA
94612-2944
US

IV. Provider business mailing address

1940 WEBSTER ST STE 200
OAKLAND CA
94612-2944
US

V. Phone/Fax

Practice location:
  • Phone: 510-463-4700
  • Fax: 510-463-4722
Mailing address:
  • Phone: 510-463-4700
  • Fax: 510-463-4722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberA67737
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: