MEDICARE: TIMOTHY D. BULGARELLI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier	CPO00731

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ42904Z	OTHER	CA	BLUE SHIELD OF CALIFORNIA

General Provider Information

NPI Number	:	1184811283
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIMOTHY D. BULGARELLI

Provider Business Mailing Address
First Line	:	454 N CRAIG AVE
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-2460
Country	:	US
Telephone Number	:	626-793-7103
Fax Number	:	626-793-8332

Provider Business Practice Location Address
First Line	:	454 N CRAIG AVE
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-2460
Country	:	US
Telephone Number	:	626-793-7103
Fax Number	:	626-793-8332

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	EMMA RICHARDSON
Credential	:
Telephone Number	:	626-793-7103

Provider Enumeration Date	:	10/02/2007
Last Update Date	:	10/17/2008

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