Healthcare Provider Details

I. General information

NPI: 1275891293
Provider Name (Legal Business Name): CASSANDRA JEWELS BULAU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S SIBLEY AVE
LITCHFIELD MN
55355-3030
US

IV. Provider business mailing address

426 S ARMSTRONG AVE
LITCHFIELD MN
55355-3004
US

V. Phone/Fax

Practice location:
  • Phone: 320-693-3233
  • Fax: 320-693-3290
Mailing address:
  • Phone: 320-693-7472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number56498
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: