Provider Demographics
NPI:1720210214
Name:BULOS, JESSE JR
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:BULOS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8413 PARKLAND DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-2637
Mailing Address - Country:US
Mailing Address - Phone:915-861-8469
Mailing Address - Fax:
Practice Address - Street 1:8413 PARKLAND DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-2637
Practice Address - Country:US
Practice Address - Phone:915-861-8469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program