Provider Demographics
NPI:1083666218
Name:BULOTSKY, ALAN B (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:B
Last Name:BULOTSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2926
Mailing Address - Country:US
Mailing Address - Phone:508-584-1890
Mailing Address - Fax:508-580-3332
Practice Address - Street 1:201 QUINCY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2926
Practice Address - Country:US
Practice Address - Phone:508-584-1890
Practice Address - Fax:508-580-3332
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA34968208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2032376Medicaid
J03186Medicare ID - Type Unspecified
MA2032376Medicaid