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General NPI Number Information
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NPI Number | 1043069651
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Entity Type | Individual
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Provider Name | JACK KEVIN BULLIS MD
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Gender | Male
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Dates
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Enumeration Date | 05/15/2024
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Last Update Date | 05/15/2024
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Provider Practice Location Address
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Address Line | 200 HAWKINS DR
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City | IOWA CITY
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State | IA
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Zip | 52242-1009
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Country | US
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Telephone | 319-356-1616
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Fax |
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Provider Business Mailing Address
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Address Line | 510 W WASHINGTON AVE APT 508
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City | MADISON
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State | WI
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Zip | 53703-2993
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Country | US
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Telephone | 715-768-0545
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | R-13133
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License Number State | IA
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