Provider Demographics
NPI:1083828719
Name:BULTEMEYER, MARLENE CLARE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARLENE
Middle Name:CLARE
Last Name:BULTEMEYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARLENE
Other - Middle Name:C
Other - Last Name:SARRAZINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7956 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4140
Mailing Address - Country:US
Mailing Address - Phone:260-436-2416
Mailing Address - Fax:260-436-9662
Practice Address - Street 1:7956 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-436-2416
Practice Address - Fax:260-436-9662
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066634A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1083828719Medicaid
OH3034657Medicaid
IN200974740Medicaid
MI1083828719Medicaid