Provider Demographics
NPI:1992442792
Name:BULTSMA, ALICIA (OD)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:BULTSMA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:905 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:PLATTE
Mailing Address - State:SD
Mailing Address - Zip Code:57369-2129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2908 DIVISION ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2437
Practice Address - Country:US
Practice Address - Phone:269-983-3309
Practice Address - Fax:269-983-0846
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4901005482152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist