Provider Demographics
NPI:1982138467
Name:BULVONY, KELSEY (DO)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:BULVONY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UH STREETSBORO FAMILY PRACTICE
Mailing Address - Street 2:9318 STATE ROUTE 14 THIRD FLOOR
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241
Mailing Address - Country:US
Mailing Address - Phone:330-626-3111
Mailing Address - Fax:330-626-5978
Practice Address - Street 1:9318 STATE ROUTE 14
Practice Address - Street 2:
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-5224
Practice Address - Country:US
Practice Address - Phone:330-626-3111
Practice Address - Fax:330-626-5978
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.014275207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100230031Medicaid