Provider Demographics
NPI:1063653947
Name:BULLOCK, CARLETTA SARAH (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLETTA
Middle Name:SARAH
Last Name:BULLOCK
Suffix:
Gender:F
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 36021
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87176-6021
Mailing Address - Country:US
Mailing Address - Phone:505-265-6383
Mailing Address - Fax:
Practice Address - Street 1:4300 BLAKE RD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-5179
Practice Address - Country:US
Practice Address - Phone:505-243-1118
Practice Address - Fax:505-903-5832
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM9316207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine