Provider Demographics
NPI:1316946189
Name:BULTMAN, RICHARD J (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:BULTMAN
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 1:1594 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4546
Mailing Address - Country:US
Mailing Address - Phone:904-264-8621
Mailing Address - Fax:904-215-9418
Practice Address - Street 1:1594 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4546
Practice Address - Country:US
Practice Address - Phone:904-264-8621
Practice Address - Fax:904-215-9418
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME017622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000458300Medicaid
FL02009OtherBLUE CROSS BLUE SHIELD
FLME017622OtherFL LICENSE
FL02009WMedicare PIN
FL02009OtherBLUE CROSS BLUE SHIELD
FLD50289Medicare UPIN
FLRR P00709646Medicare PIN