Healthcare Provider Details

I. General information

NPI: 1609897313
Provider Name (Legal Business Name): PONCE D BULLARD JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 08/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2728 SUNSET BLVD SUITE 310
WEST COLUMBIA SC
29169
US

IV. Provider business mailing address

2728 SUNSET BLVD SUITE 310
WEST COLUMBIA SC
29169
US

V. Phone/Fax

Practice location:
  • Phone: 803-936-8080
  • Fax: 803-936-8079
Mailing address:
  • Phone: 803-936-8080
  • Fax: 803-936-8079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number7127
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: