Healthcare Provider Details

I. General information

NPI: 1326663642
Provider Name (Legal Business Name): TRON LEWILL BULLARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

2915 WESTCHESTER CT
AUGUSTA GA
30909-2015
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-4915
  • Fax:
Mailing address:
  • Phone: 404-798-8430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number91314
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: