Provider Demographics
NPI:1114981602
Name:BULATAO, IMELDA S (MD)
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:S
Last Name:BULATAO
Suffix:
Gender:F
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:PO BOX 3637
Mailing Address - Street 2:ATTN JUDY H NOWLIN
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404
Mailing Address - Country:US
Mailing Address - Phone:423-629-7688
Mailing Address - Fax:423-495-6175
Practice Address - Street 1:2525 DESALES AVE
Practice Address - Street 2:PATHOLOGY LABORATORY
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404
Practice Address - Country:US
Practice Address - Phone:423-495-8703
Practice Address - Fax:423-495-6175
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35906207ZD0900X
MOR7H57207ZD0900X
TNMD00040961207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F05442Medicare UPIN
PA008179Medicare ID - Type Unspecified
TN3338528Medicare PIN