=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598935249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEAL M BULLOCK DPM PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2008
-----------------------------------------------------
Last Update Date | 05/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17013 PINES BLVD
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33027-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-450-4200
-----------------------------------------------------
Fax | 954-450-4237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17013 PINES BLVD
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33027-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-450-4200
-----------------------------------------------------
Fax | 954-450-4237
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OWNER
-----------------------------------------------------
Name | DR. NEAL M BULLOCK
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 954-450-4200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | PO2571
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------