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General NPI Number Information
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NPI Number | 1205630100
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Entity Type | Individual
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Provider Name | MATTHEW BROOKS BULKLEY MD
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Gender | Male
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Dates
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Enumeration Date | 04/02/2025
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Last Update Date | 04/02/2025
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Provider Practice Location Address
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Address Line | 19000 ST JOES PKWY STE 310
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City | LIVONIA
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State | MI
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Zip | 48152-1477
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Country | US
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Telephone | 734-743-4540
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Fax |
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Provider Business Mailing Address
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Address Line | 391 N VINEYARD RIDGE DR
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City | ST GEORGE
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State | UT
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Zip | 84770-1348
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Country | US
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Telephone | 435-429-9930
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Fax |
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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