Provider Demographics
NPI:1750053559
Name:BULATOVIC, STEFAN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:STEFAN
Middle Name:
Last Name:BULATOVIC
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3644 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-4430
Mailing Address - Country:US
Mailing Address - Phone:619-559-5305
Mailing Address - Fax:
Practice Address - Street 1:2810 CAMINO DEL RIO S STE 102
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3819
Practice Address - Country:US
Practice Address - Phone:619-299-1419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018067363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health