Provider Demographics
NPI:1093869786
Name:BULLOCK, MELVIN DANA (MD)
Entity Type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:DANA
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 1:11685 ALPHARETTA HWY
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4913
Mailing Address - Country:US
Mailing Address - Phone:770-442-5882
Mailing Address - Fax:470-514-3759
Practice Address - Street 1:11685 ALPHARETTA HWY
Practice Address - Street 2:SUITE 320
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4913
Practice Address - Country:US
Practice Address - Phone:770-442-5882
Practice Address - Fax:470-514-3759
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063638207R00000X
FLME105404207R00000X
GA63638207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL146KWOtherBC/BS
FLP00782776OtherRR MEDICARE
GA003101130DMedicaid
GA003101130EMedicaid
FLP00782776OtherRR MEDICARE
GA003101130EMedicaid
GA003101130DMedicaid
GA202I119138Medicare PIN