Provider Demographics
NPI:1164612370
Name:BULLOCK, COLETTE DEVONA (DO)
Entity Type:Individual
Prefix:DR
First Name:COLETTE
Middle Name:DEVONA
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:COLETTE
Other - Middle Name:DEVONA
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5422 CUMMING HWY STE 104
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-7027
Mailing Address - Country:US
Mailing Address - Phone:678-765-7147
Mailing Address - Fax:877-991-5350
Practice Address - Street 1:5422 CUMMING HWY STE 104
Practice Address - Street 2:
Practice Address - City:SUGAR HILL
Practice Address - State:GA
Practice Address - Zip Code:30518-7027
Practice Address - Country:US
Practice Address - Phone:678-466-9193
Practice Address - Fax:877-991-5350
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2022-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015213207R00000X
NJ25MB08802400207R00000X
GA75415207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty