Provider Demographics
NPI:1649362724
Name:PULTORAK, PAUL R (DO)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:PULTORAK
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8560
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:360 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-907-1430
Practice Address - Fax:207-907-3508
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2022-02-03
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Provider Licenses
StateLicense IDTaxonomies
MEDO1960207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HX5041Medicare PIN
MEME2144Medicare PIN