Provider Demographics
NPI:1225359805
Name:PETER BULLOCK MD PC
Entity Type:Organization
Organization Name:PETER BULLOCK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-256-6000
Mailing Address - Street 1:206 N MUSTANG MALL TER
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-5135
Mailing Address - Country:US
Mailing Address - Phone:405-256-6000
Mailing Address - Fax:405-256-6001
Practice Address - Street 1:206 N MUSTANG MALL TER
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-5135
Practice Address - Country:US
Practice Address - Phone:405-256-6000
Practice Address - Fax:405-256-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPENDINGMedicaid
OKPENDINGMedicare PIN