Provider Demographics
NPI:1326014945
Name:BULT, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:BULT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1500 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3011
Mailing Address - Country:US
Mailing Address - Phone:417-326-6000
Mailing Address - Fax:417-328-6338
Practice Address - Street 1:1155 W PARKVIEW
Practice Address - Street 2:SUITE 1C
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-7800
Practice Address - Country:US
Practice Address - Phone:417-326-7246
Practice Address - Fax:417-777-2968
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5G60174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
909103888Medicare Oscar/Certification