Provider Demographics
NPI:1184811283
Name:TIMOTHY D. BULGARELLI
Entity type:Organization
Organization Name:TIMOTHY D. BULGARELLI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-793-7103
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CPO00731335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ42904ZOtherBLUE SHIELD OF CALIFORNIA
CAZZZ42904ZOtherBLUE SHIELD OF CALIFORNIA