Provider Demographics
NPI:1043268709
Name:BULLOCK, JOHNNY (MD)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:FOXWORTH
Mailing Address - State:MS
Mailing Address - Zip Code:39483-0669
Mailing Address - Country:US
Mailing Address - Phone:601-424-3540
Mailing Address - Fax:601-424-3544
Practice Address - Street 1:62 HIGHWAY 587
Practice Address - Street 2:
Practice Address - City:FOXWORTH
Practice Address - State:MS
Practice Address - Zip Code:39483-5026
Practice Address - Country:US
Practice Address - Phone:601-424-3540
Practice Address - Fax:601-424-3544
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00737837Medicaid
MS302I068514Medicare PIN
MS00737837Medicaid