Provider Demographics
NPI:1821123035
Name:BULGER, JOHN WALTER (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WALTER
Last Name:BULGER
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 1:303 S MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2189
Mailing Address - Country:US
Mailing Address - Phone:574-255-8285
Mailing Address - Fax:574-255-8341
Practice Address - Street 1:303 S MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2189
Practice Address - Country:US
Practice Address - Phone:574-255-8285
Practice Address - Fax:574-255-8341
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034598A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100091420AMedicaid
INBU164930Medicare ID - Type Unspecified
INE06643Medicare UPIN