Healthcare Provider Details

I. General information

NPI: 1255015087
Provider Name (Legal Business Name): CAMERON HURLOCK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E WASHINGTON ST
BLOOMINGTON IL
61701-4364
US

IV. Provider business mailing address

2200 E WASHINGTON ST
BLOOMINGTON IL
61701-4364
US

V. Phone/Fax

Practice location:
  • Phone: 928-920-1463
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.082541
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: