Healthcare Provider Details

I. General information

NPI: 1649362724
Provider Name (Legal Business Name): PAUL R PULTORAK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 BROADWAY
BANGOR ME
04401
US

IV. Provider business mailing address

C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT PO BOX 7291
LEWISTON ME
04243-7291
US

V. Phone/Fax

Practice location:
  • Phone: 207-907-1430
  • Fax: 207-907-3508
Mailing address:
  • Phone: 207-777-8560
  • Fax: 207-777-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberDO1960
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: