Provider Demographics
NPI:1932215944
Name:BULATOV, MARINA (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARINA
Middle Name:
Last Name:BULATOV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 WEBSTER ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-2944
Mailing Address - Country:US
Mailing Address - Phone:510-463-4700
Mailing Address - Fax:510-463-4722
Practice Address - Street 1:1940 WEBSTER ST STE 200
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2944
Practice Address - Country:US
Practice Address - Phone:510-463-4700
Practice Address - Fax:510-463-4722
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67737208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A6776730Medicare ID - Type Unspecified
CAG94465Medicare UPIN