Healthcare Provider Details

I. General information

NPI: 1942217757
Provider Name (Legal Business Name): JOHN DAVID BULLOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1238 HIGHWAY 42
SUMRALL MS
39482
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-758-3100
  • Fax: 601-758-3008
Mailing address:
  • Phone: 601-758-3100
  • Fax: 601-579-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12095
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: