Provider Demographics
NPI:1164517611
Name:BULLOCK, PAUL E (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:E
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 ANDERSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-4072
Mailing Address - Country:US
Mailing Address - Phone:785-776-9461
Mailing Address - Fax:785-776-9946
Practice Address - Street 1:1441 ANDERSON AVENUE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-4072
Practice Address - Country:US
Practice Address - Phone:785-776-9461
Practice Address - Fax:785-776-9946
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS912-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS912-3OtherSTATE LICENSE NUMBER
KS651053Medicare ID - Type Unspecified
KS912-3OtherSTATE LICENSE NUMBER