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General NPI Number Information
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NPI Number | 1700149804
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Entity Type | Individual
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Provider Name | MICHAEL BRENT BULLOCH D.O.
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Gender | Male
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Dates
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Enumeration Date | 06/22/2012
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Last Update Date | 10/22/2024
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Provider Practice Location Address
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Address Line | 110 W 1325 N STE 200
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City | CEDAR CITY
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State | UT
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Zip | 84721-8179
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Country | US
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Telephone | 435-586-7676
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Fax |
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Provider Business Mailing Address
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Address Line | 110 W 1325 N STE 200
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City | CEDAR CITY
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State | UT
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Zip | 84721-8179
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Country | US
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Telephone | 435-586-7676
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 94725281204
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License Number State | UT
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