Provider Demographics
NPI:1356506935
Name:BULLOCK, PETER PAUL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:PAUL
Last Name:BULLOCK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:106 S CASTLEROCK LN
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-4586
Mailing Address - Country:US
Mailing Address - Phone:405-256-0374
Mailing Address - Fax:
Practice Address - Street 1:106 S CASTLEROCK LN
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-4586
Practice Address - Country:US
Practice Address - Phone:405-256-0374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25803207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK25803OtherOKLAHOMA MEDICAL LICENSE