Provider Demographics
NPI:1053409698
Name:WULKAN, MARK L (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:WULKAN
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 1:1 PERKINS SQ
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44308-1063
Mailing Address - Country:US
Mailing Address - Phone:330-543-1000
Mailing Address - Fax:
Practice Address - Street 1:1 PERKINS SQ
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44308-1063
Practice Address - Country:US
Practice Address - Phone:330-543-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0456762086S0120X
OH35.1391932086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA37BBFHJOtherMEDICARE PTAN
GA37BBFHJOtherMEDICARE PTAN