Provider Demographics
NPI:1063473841
Name:BULLIS, WM JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:WM
Middle Name:JOHN
Last Name:BULLIS
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 1:8610 NE 17TH ST
Mailing Address - Street 2:
Mailing Address - City:CLYDE HILL
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3241
Mailing Address - Country:US
Mailing Address - Phone:509-720-0691
Mailing Address - Fax:
Practice Address - Street 1:8610 NE 17TH ST
Practice Address - Street 2:
Practice Address - City:CLYDE HILL
Practice Address - State:WA
Practice Address - Zip Code:98004-3241
Practice Address - Country:US
Practice Address - Phone:509-720-0691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60033065207VG0400X
IDM-10613207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
86806OtherMEDCOST
FH1000860OtherFIRST CAROLINA CARE
NC8911941Medicaid
SCN0044AMedicaid
9663436OtherGHI
160051634OtherMEDICARE RAILROAD
11941OtherBLUE CROSS BLUE SHIELD
11941OtherBLUE CROSS BLUE SHIELD
9663436OtherGHI