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General NPI Number Information
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NPI Number | 1114981602
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Entity Type | Individual
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Provider Name | IMELDA S BULATAO MD
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Gender | Female
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Dates
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Enumeration Date | 04/13/2006
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Last Update Date | 09/28/2007
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Provider Practice Location Address
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Address Line | 2525 DESALES AVE PATHOLOGY LABORATORY
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City | CHATTANOOGA
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State | TN
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Zip | 37404
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Country | US
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Telephone | 423-495-8703
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Fax | 423-495-6175
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Provider Business Mailing Address
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Address Line | PO BOX 3637 ATTN JUDY H NOWLIN
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City | CHATTANOOGA
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State | TN
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Zip | 37404
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Country | US
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Telephone | 423-629-7688
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Fax | 423-495-6175
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZD0900X
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Taxonomy Name | Dermatopathology (Pathology) Physician
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License Number | 35906
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 207ZD0900X
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Taxonomy Name | Dermatopathology (Pathology) Physician
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License Number | R7H57
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | MD00040961
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License Number State | TN
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