Healthcare Provider Details

I. General information

NPI: 1043478027
Provider Name (Legal Business Name): BULLOCK OPTOMETRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 12/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2373 E MAIN ST
PLAINFIELD IN
46168-2717
US

IV. Provider business mailing address

114 KINGSVIEW DR
MOORESVILLE IN
46158-2734
US

V. Phone/Fax

Practice location:
  • Phone: 317-839-0713
  • Fax:
Mailing address:
  • Phone: 317-417-0603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002990A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200918100A
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer
# 2
Identifier200918100B
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name: CARMEN N BULLOCK
Title or Position: PRESIDENT
Credential: OD
Phone: 317-417-0603