Provider Demographics
NPI:1164876553
Name:BULWA, ZACHARY B (MD, MS)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:B
Last Name:BULWA
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CENTRAL ST STE 880
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1780
Mailing Address - Country:US
Mailing Address - Phone:847-570-2570
Mailing Address - Fax:847-570-2073
Practice Address - Street 1:1000 CENTRAL ST STE 880
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1780
Practice Address - Country:US
Practice Address - Phone:847-570-2570
Practice Address - Fax:847-570-2073
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361525092084N0400X
IL125.0685412084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program