Provider Demographics
NPI:1093704355
Name:BULLOCK, RICHARD BARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:BARRY
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 1:225 MAY STREET
Mailing Address - Street 2:SUITE E
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837
Mailing Address - Country:US
Mailing Address - Phone:732-661-2020
Mailing Address - Fax:732-661-2022
Practice Address - Street 1:225 MAY STREET
Practice Address - Street 2:SUITE E
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837
Practice Address - Country:US
Practice Address - Phone:732-661-2020
Practice Address - Fax:732-661-2022
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04808400207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0468801Medicaid
NJ568246Medicare ID - Type Unspecified
NJ0468801Medicaid