Healthcare Provider Details

I. General information

NPI: 1366076556
Provider Name (Legal Business Name): EDWIN PETER BULLARD BCO, BADO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4606 S GARNETT RD STE 302
TULSA OK
74146-5218
US

IV. Provider business mailing address

4606 S GARNETT RD STE 302
TULSA OK
74146-5218
US

V. Phone/Fax

Practice location:
  • Phone: 918-664-6544
  • Fax: 918-664-0668
Mailing address:
  • Phone: 918-664-6544
  • Fax: 918-664-0668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: