MEDICARE: DR. FORREST A BULLOCK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	7575794-1205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497730642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FORREST A BULLOCK M.D.

Provider Business Mailing Address
First Line	:	5268 W BOWSTRING WAY
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84009-6161
Country	:	US
Telephone Number	:	307-760-3869
Fax Number	:

Provider Business Practice Location Address
First Line	:	5268 W BOWSTRING WAY
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84009-6161
Country	:	US
Telephone Number	:	307-760-3869
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2005
Last Update Date	:	12/14/2018

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