Basic Information
| Provider Information | |||||||||
| NPI: | 1902544265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BULT | ||||||||
| FirstName: | KATELYN | ||||||||
| MiddleName: | WANG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8614 WESTWOOD CENTER DR FL 9 | ||||||||
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| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221822442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 5408 N CLARK ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606401210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732752020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2022 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046011623 | IL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.