Healthcare Provider Details

I. General information

NPI: 1295743045
Provider Name (Legal Business Name): ANDREW COLIN BULLOCK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5575 RUFFIN RD #100
SAN DIEGO CA
92123-1380
US

IV. Provider business mailing address

PO BOX 33707
SAN DIEGO CA
92163-3707
US

V. Phone/Fax

Practice location:
  • Phone: 858-492-5410
  • Fax: 858-492-5411
Mailing address:
  • Phone: 858-492-5410
  • Fax: 858-492-5411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number20A6842
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: