Provider Demographics
NPI:1043478027
Name:BULLOCK OPTOMETRY PC
Entity Type:Organization
Organization Name:BULLOCK OPTOMETRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:N
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-417-0603
Mailing Address - Street 1:114 KINGSVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-2734
Mailing Address - Country:US
Mailing Address - Phone:317-417-0603
Mailing Address - Fax:
Practice Address - Street 1:2373 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-2717
Practice Address - Country:US
Practice Address - Phone:317-839-0713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002990A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200918100AMedicaid
IN200918100BMedicaid
IN200918100AMedicaid