Healthcare Provider Details

I. General information

NPI: 1033522784
Provider Name (Legal Business Name): BRANDON BULTSMA D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
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

3558 ROOKWOOD PL
JOHNS ISLAND SC
29455-8183
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number707
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901002526
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: