Provider Demographics
NPI:1023177268
Name:BULTEN, ROBERT (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BULTEN
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 1:4340 BURLINGAME AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-3770
Mailing Address - Country:US
Mailing Address - Phone:616-475-7922
Mailing Address - Fax:616-475-7926
Practice Address - Street 1:4340 BURLINGAME AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-3770
Practice Address - Country:US
Practice Address - Phone:616-475-7922
Practice Address - Fax:616-475-7926
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010287032080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3305965Medicaid
MIF49097Medicare UPIN