Healthcare Provider Details

I. General information

NPI: 1508046376
Provider Name (Legal Business Name): EDGAR MARK BULLOCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 W MAIN ST STE 100
EL CAJON CA
92020-3325
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4541
US

V. Phone/Fax

Practice location:
  • Phone: 619-401-0404
  • Fax:
Mailing address:
  • Phone: 619-515-2323
  • Fax: 619-906-4564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberBP10025759
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA113241
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: