Provider Demographics
NPI:1851516785
Name:ISIDRO M BULATAO MD PC
Entity Type:Organization
Organization Name:ISIDRO M BULATAO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ISIDRO
Authorized Official - Middle Name:M
Authorized Official - Last Name:BULATAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-235-3990
Mailing Address - Street 1:PO BOX 986
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110
Mailing Address - Country:US
Mailing Address - Phone:518-235-3990
Mailing Address - Fax:518-235-9177
Practice Address - Street 1:190 5TH AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180
Practice Address - Country:US
Practice Address - Phone:518-235-3990
Practice Address - Fax:518-235-9177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY097438208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10000230OtherCDPHP
NY20365OtherBLUE CROSS
NY00529300Medicaid
B82665Medicare UPIN
NY20365OtherBLUE CROSS