Healthcare Provider Details

I. General information

NPI: 1710079736
Provider Name (Legal Business Name): KENT BULLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HO PLZ
ITHACA NY
14853-3102
US

IV. Provider business mailing address

110 HO PLZ
ITHACA NY
14853-3102
US

V. Phone/Fax

Practice location:
  • Phone: 607-255-5155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number1034097
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: