Healthcare Provider Details

I. General information

NPI: 1700923778
Provider Name (Legal Business Name): DANNY WAYNE BULLARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 24 48 HIGHWAY
TUPELO OK
74572-9706
US

IV. Provider business mailing address

PO BOX 188
TUPELO OK
74572-0188
US

V. Phone/Fax

Practice location:
  • Phone: 580-927-5158
  • Fax:
Mailing address:
  • Phone: 580-927-5158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: