Provider Demographics
NPI:1295790350
Name:BULGER, ROBERTA ANNE (MD)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:ANNE
Last Name:BULGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:ANNE
Other - Last Name:EGGEBRAATEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 92900
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11510 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-3356
Practice Address - Country:US
Practice Address - Phone:503-256-0636
Practice Address - Fax:503-408-7034
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09855207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR146936Medicaid
OR146936Medicaid
C92317Medicare UPIN