Provider Demographics
NPI:1194717447
Name:BULENGO, STELLA M (MD)
Entity type:Individual
Prefix:
First Name:STELLA
Middle Name:M
Last Name:BULENGO
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 1:18018 OVERLOOK LOOP STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259-1883
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3320 OAKWELL CT
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218-3128
Practice Address - Country:US
Practice Address - Phone:210-829-5180
Practice Address - Fax:210-829-5030
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG183935207N00000X
TXS2739207N00000X
GA050931207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME129589OtherFL MEDICAL LICENSE
TXS2739OtherTX MEDICAL LICENSE
GA07BBSVCMedicare PIN
GA1790989291OtherGROUP NPI
E82056Medicare UPIN