Provider Demographics
NPI:1710022546
Name:BULGARELLI, TIMOTHY DANIEL (CPO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DANIEL
Last Name:BULGARELLI
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 N CRAIG AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-2460
Mailing Address - Country:US
Mailing Address - Phone:626-793-7103
Mailing Address - Fax:626-793-8332
Practice Address - Street 1:454 N CRAIG AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-2460
Practice Address - Country:US
Practice Address - Phone:626-793-7103
Practice Address - Fax:626-793-8332
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CPO00731222Z00000X, 224P00000X, 225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Not Answered225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ42904ZOtherBLUE SHIELD OF CALIFORNIA
CAXC0007310Medicaid
CAXC0007310Medicaid