1477740975 NPI number — LARRY A BULAHAO DPM PA

Table of content: (NPI 1477740975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477740975 NPI number — LARRY A BULAHAO DPM PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARRY A BULAHAO DPM PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477740975
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8835 SAGEBRUSH LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78217-5822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-599-3008
Provider Business Mailing Address Fax Number:
210-599-6175

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8835 SAGEBRUSH LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78217-5822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-599-3008
Provider Business Practice Location Address Fax Number:
210-599-6175
Provider Enumeration Date:
09/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BULAHAO
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
AJOLO
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
210-599-3008

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X , with the licence number:  1606 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 157842901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00216950 . This is a "RR MCR" identifier . This identifiers is of the category "OTHER".




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