Provider Demographics
NPI:1134291107
Name:BULLARD, JAMES D (PT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:D
Last Name:BULLARD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 SE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-5127
Mailing Address - Country:US
Mailing Address - Phone:816-524-6488
Mailing Address - Fax:816-524-6488
Practice Address - Street 1:2950 NE JELLISON RD
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-0900
Practice Address - Country:US
Practice Address - Phone:816-507-3260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1018052251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO486710726Medicaid
MO22381016OtherBLUE CROSS BLUE SHIELD IN