Provider Demographics
NPI:1740370493
Name:BULALA, RICARDO ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:ANTONIO
Last Name:BULALA
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 1:3719 MARVEL DR
Mailing Address - Street 2:
Mailing Address - City:TRAPPE
Mailing Address - State:MD
Mailing Address - Zip Code:21673-1782
Mailing Address - Country:US
Mailing Address - Phone:410-476-5717
Mailing Address - Fax:
Practice Address - Street 1:201 W PRESTON ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-2301
Practice Address - Country:US
Practice Address - Phone:410-767-6713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0025272251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare