Provider Demographics
NPI:1790743342
Name:BULAEVA, NATALYA V (MD)
Entity Type:Individual
Prefix:
First Name:NATALYA
Middle Name:V
Last Name:BULAEVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 BAYTREE LN
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4162
Mailing Address - Country:US
Mailing Address - Phone:904-860-1123
Mailing Address - Fax:
Practice Address - Street 1:1750 STOCKTON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204
Practice Address - Country:US
Practice Address - Phone:904-860-1123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA074839208100000X
FLME117366208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003169167AMedicaid