Provider Demographics
NPI:1962421180
Name:BULAHAO, LARRY AJOLO (DPM)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:AJOLO
Last Name:BULAHAO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2441 NACOGDOCHES RD
Mailing Address - Street 2:# 806
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-6044
Mailing Address - Country:US
Mailing Address - Phone:210-599-3008
Mailing Address - Fax:210-599-6175
Practice Address - Street 1:2441 NACOGDOCHES RD
Practice Address - Street 2:# 806
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-6044
Practice Address - Country:US
Practice Address - Phone:210-859-7718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1606213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX157842901Medicaid
TXP00216950OtherRR MEDICARE
TXP00450858OtherRR MEDICARE
TX157844502Medicaid
TX157842901Medicaid
4937640001Medicare NSC
TXP00216950OtherRR MEDICARE
TX8A6036Medicare PIN
TX8J6640Medicare PIN