Provider Demographics
NPI:1326020199
Name:BULAWA, ERICK C (MD)
Entity Type:Individual
Prefix:DR
First Name:ERICK
Middle Name:C
Last Name:BULAWA
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 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:438 E VANN RD STE 201
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37743-7202
Practice Address - Country:US
Practice Address - Phone:423-278-1800
Practice Address - Fax:423-278-1805
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN179208207RB0002X, 208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ001917Medicaid
NY01458891Medicaid
TN4357373OtherBCBST
TNP01237829OtherRAILROAD MEDICARE
NYF59791Medicare UPIN
NY01458891Medicaid
TN103112I433Medicare PIN