Provider Demographics
NPI:1003814492
Name:BULLION, BRUCE L (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:BULLION
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2024
Mailing Address - Country:US
Mailing Address - Phone:616-846-0620
Mailing Address - Fax:616-844-6079
Practice Address - Street 1:1960 28TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-7900
Practice Address - Country:US
Practice Address - Phone:616-247-6677
Practice Address - Fax:616-247-1254
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004093152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4634126Medicaid
MI4703359Medicaid
MI4939450Medicaid
MI4930876Medicaid
MI4947087Medicaid
MI4930876Medicaid
MI4634126Medicaid
MI4703359Medicaid
MIP00151235Medicare ID - Type UnspecifiedRAILROAD INDIVIDUAL
MIN96840002Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
MIDC1560Medicare ID - Type UnspecifiedRAILROAD MEDICARE GROUP
MI5189400001Medicare NSC
MI0P21400Medicare ID - Type UnspecifiedMICHIGAN MEDICARE GROUP
MI5189400005Medicare NSC
MI4947087Medicaid
MIP21400009Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBR
MI5472600009Medicare NSC