Healthcare Provider Details

I. General information

NPI: 1396232880
Provider Name (Legal Business Name): BRANDON C BULTSMA, DPM, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1565 SAM RITTENBERG BLVD STE 104
CHARLESTON SC
29407-4128
US

IV. Provider business mailing address

1565 SAM RITTENBERG BLVD STE 100
CHARLESTON SC
29407-4128
US

V. Phone/Fax

Practice location:
  • Phone: 854-444-3129
  • Fax:
Mailing address:
  • Phone: 843-642-0074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: BRANDON BULTSMA
Title or Position: PRESIDENT
Credential: DPM
Phone: 854-444-3129