Provider Demographics
NPI:1265653943
Name:BULLARD, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:BULLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 E. WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077
Mailing Address - Country:US
Mailing Address - Phone:440-354-1135
Mailing Address - Fax:440-354-1089
Practice Address - Street 1:10 E. WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077
Practice Address - Country:US
Practice Address - Phone:440-354-1135
Practice Address - Fax:440-354-1089
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-031738B207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0292857Medicaid
OHC01580Medicare UPIN
OHO455291Medicare ID - Type Unspecified