Healthcare Provider Details

I. General information

NPI: 1477740975
Provider Name (Legal Business Name): LARRY A BULAHAO DPM PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8835 SAGEBRUSH LN
SAN ANTONIO TX
78217-5822
US

IV. Provider business mailing address

8835 SAGEBRUSH LN
SAN ANTONIO TX
78217-5822
US

V. Phone/Fax

Practice location:
  • Phone: 210-599-3008
  • Fax: 210-599-6175
Mailing address:
  • Phone: 210-599-3008
  • Fax: 210-599-6175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number1606
License Number StateTX

VIII. Authorized Official

Name: DR. LARRY AJOLO BULAHAO
Title or Position: OWNER
Credential: DPM
Phone: 210-599-3008