Healthcare Provider Details

I. General information

NPI: 1558313536
Provider Name (Legal Business Name): LYNN BULLOCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3207 N ACADEMY BLVD SUITE 300
COLORADO SPRINGS CO
80917-5100
US

IV. Provider business mailing address

3207 N ACADEMY BLVD SUITE 300
COLORADO SPRINGS CO
80917-5100
US

V. Phone/Fax

Practice location:
  • Phone: 719-597-8704
  • Fax: 719-597-6864
Mailing address:
  • Phone: 719-597-8704
  • Fax: 719-597-6864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36874
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: