Healthcare Provider Details

I. General information

NPI: 1578907671
Provider Name (Legal Business Name): THOMAS J BULLOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2013
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 116TH AVE NE STE 500
BELLEVUE WA
98004-4627
US

IV. Provider business mailing address

1135 116TH AVE NE STE 500
BELLEVUE WA
98004-4627
US

V. Phone/Fax

Practice location:
  • Phone: 801-699-8936
  • Fax:
Mailing address:
  • Phone: 425-635-6560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberBP10047662
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberDR.0058235
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number61345139
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number1578907671
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: