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General NPI Number Information
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NPI Number | 1649362724
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Entity Type | Individual
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Provider Name | PAUL R PULTORAK D.O.
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Gender | Male
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Dates
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Enumeration Date | 09/28/2006
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Last Update Date | 02/03/2022
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Provider Practice Location Address
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Address Line | 360 BROADWAY
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City | BANGOR
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State | ME
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Zip | 04401
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Country | US
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Telephone | 207-907-1430
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Fax | 207-907-3508
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Provider Business Mailing Address
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Address Line | C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT PO BOX 7291
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City | LEWISTON
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State | ME
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Zip | 04243-7291
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Country | US
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Telephone | 207-777-8560
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Fax | 207-777-8800
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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 | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | DO1960
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License Number State | ME
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