Provider Demographics
NPI:1265465397
Name:LANCE E BULLOCK, MD, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LANCE E BULLOCK, MD, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:F
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-673-8258
Mailing Address - Street 1:37459 ULTIMA PLAZA BLVD, SUITE B, PMB 227
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3856
Mailing Address - Country:US
Mailing Address - Phone:225-673-8258
Mailing Address - Fax:225-673-2340
Practice Address - Street 1:3136 S SAINT LANDRY AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-5801
Practice Address - Country:US
Practice Address - Phone:225-647-7524
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09761R2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1683728Medicaid
LA5CH16Medicare ID - Type Unspecified