Healthcare Provider Details

I. General information

NPI: 1467432666
Provider Name (Legal Business Name): JOSEPH D. BULLOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8080 RAVINES EDGE CT
COLUMBUS OH
43235-5424
US

IV. Provider business mailing address

8080 RAVINES EDGE CT
COLUMBUS OH
43235-5424
US

V. Phone/Fax

Practice location:
  • Phone: 614-846-5944
  • Fax: 614-846-6504
Mailing address:
  • Phone: 614-846-5944
  • Fax: 614-846-6504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number35-03-0076
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: