Healthcare Provider Details

I. General information

NPI: 1548237407
Provider Name (Legal Business Name): MANUEL C BULAUITAN MDPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177-06 WEXFORD TERRACE
JAMAICA ESTATES NY
11432-2927
US

IV. Provider business mailing address

177-06 WEXFORD TERRACE
JAMAICA ESTATES NY
11432-2927
US

V. Phone/Fax

Practice location:
  • Phone: 718-291-9384
  • Fax:
Mailing address:
  • Phone: 718-291-9384
  • Fax: 718-558-9020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number121369
License Number StateNY

VIII. Authorized Official

Name: MANUEL C BULAUITAN
Title or Position: OWNER
Credential: MD
Phone: 718-291-9384