=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619902764
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEN JIRO BULPITT MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 03/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | UCLA MEDICAL GROUP 200 MEDICAL PLAZA, B365
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90095-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-743-5203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 VETERAN AVE DIVISION OF RHEUMATOLOGY
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90095-1670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-743-5203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | G59166
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------