Provider Demographics
NPI:1326351727
Name:BULLARD, MICHAEL LONNIE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LONNIE
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 1:4360 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1866
Mailing Address - Country:US
Mailing Address - Phone:801-476-0494
Mailing Address - Fax:801-476-0067
Practice Address - Street 1:4360 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1866
Practice Address - Country:US
Practice Address - Phone:801-476-0494
Practice Address - Fax:801-476-0067
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9073398-1205207WX0110X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000087008Medicare PIN