Healthcare Provider Details

I. General information

NPI: 1407010200
Provider Name (Legal Business Name): MANUEL C BULAUITAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 06 WEXFORD TERRACE
JAMAICA ESTATES NY
11432
US

IV. Provider business mailing address

177 06 WEXFORD TERRACE
JAMAICA ESTATES NY
11432
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number121369
License Number StateNY

VIII. Authorized Official

Name: MANUEL C BULAUITAN
Title or Position: SOLE PROPRIETER
Credential:
Phone: 718-291-9384