Provider Demographics
NPI:1336308444
Name:BULLOCK, SMITHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SMITHA
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-585-4802
Mailing Address - Fax:502-589-1256
Practice Address - Street 1:601 S FLOYD ST
Practice Address - Street 2:SUITE 602
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1845
Practice Address - Country:US
Practice Address - Phone:502-585-4802
Practice Address - Fax:502-589-1256
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY455112080P0202X
NY248041208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100224090Medicaid
KY7100224090Medicaid