Provider Demographics
NPI:1699768622
Name:BULACAN, FREDERICK K (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:K
Last Name:BULACAN
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:W180N8000 TOWN HALL RD
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-4002
Mailing Address - Country:US
Mailing Address - Phone:262-255-2500
Mailing Address - Fax:
Practice Address - Street 1:W180N8000 TOWN HALL RD
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-4002
Practice Address - Country:US
Practice Address - Phone:262-255-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35691207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI046573840OtherMEDICARE PTAN
WI042368480OtherMEDICARE PTAN
WI042368480OtherMEDICARE PTAN
WI046573840OtherMEDICARE PTAN