MEDICARE: GINA M BULLOCK DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	DP00244	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255440020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA M BULLOCK DPM

Provider Business Mailing Address
First Line	:	3508 NE BROADWAY ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97232-1821
Country	:	US
Telephone Number	:	503-282-8777
Fax Number	:	503-282-8853

Provider Business Practice Location Address
First Line	:	3508 NE BROADWAY ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97232-1821
Country	:	US
Telephone Number	:	503-282-8777
Fax Number	:	503-282-8853

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	03/07/2023

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Directions to “ GINA M BULLOCK DPM” Practice Location

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