Healthcare Provider Details

I. General information

NPI: 1114981602
Provider Name (Legal Business Name): IMELDA S BULATAO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 DESALES AVE PATHOLOGY LABORATORY
CHATTANOOGA TN
37404
US

IV. Provider business mailing address

PO BOX 3637 ATTN JUDY H NOWLIN
CHATTANOOGA TN
37404
US

V. Phone/Fax

Practice location:
  • Phone: 423-495-8703
  • Fax: 423-495-6175
Mailing address:
  • Phone: 423-629-7688
  • Fax: 423-495-6175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number35906
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberR7H57
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD00040961
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: