Healthcare Provider Details

I. General information

NPI: 1356506935
Provider Name (Legal Business Name): PETER PAUL BULLOCK JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 S WESTERN AVE
OKLAHOMA CITY OK
73170-6084
US

IV. Provider business mailing address

601 S HARBOUR ISLAND BLVD STE 200
TAMPA FL
33602-5925
US

V. Phone/Fax

Practice location:
  • Phone: 405-254-7529
  • Fax: 405-254-7587
Mailing address:
  • Phone: 727-322-3439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25803
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: