Healthcare Provider Details

I. General information

NPI: 1275277733
Provider Name (Legal Business Name): BLAINE BULLOCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 N 7TH ST
WEST MONROE LA
71291-4414
US

IV. Provider business mailing address

1804 N 7TH ST
WEST MONROE LA
71291-4414
US

V. Phone/Fax

Practice location:
  • Phone: 318-325-2610
  • Fax: 318-325-7715
Mailing address:
  • Phone: 318-325-2610
  • Fax: 318-325-7715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number352183
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: