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General NPI Number Information
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NPI Number | 1902778293
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Entity Type | Organization
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Legal Business Name | PONOS CARE ILLINOIS, PLLC
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Dates
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Enumeration Date | 09/18/2025
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Last Update Date | 09/18/2025
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Provider Practice Location Address
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Address Line | 1501 MAPLE AVE STE 305
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City | RICHMOND
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State | VA
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Zip | 23226-2553
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Country | US
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Telephone | 757-704-1000
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Fax | 757-271-6449
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Provider Business Mailing Address
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Address Line | 3005 WESTCHESTER AVE
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City | ELLICOTT CITY
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State | MD
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Zip | 21043-4753
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Country | US
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Telephone | 757-274-0334
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Fax | 757-271-6449
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GILBERTO BULTRON
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Credential | MD
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Telephone | 818-856-6696
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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