Provider Demographics
NPI:1376863902
Name:BULLOCK, MELISSA MCLEAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MCLEAN
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:CARRIE
Other - Last Name:MCLEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1340 HAL GREER BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3804
Mailing Address - Country:US
Mailing Address - Phone:304-399-6727
Mailing Address - Fax:304-399-6726
Practice Address - Street 1:1340 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3804
Practice Address - Country:US
Practice Address - Phone:304-399-6727
Practice Address - Fax:304-399-6726
Is Sole Proprietor?:No
Enumeration Date:2010-06-05
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-02005207RH0002X
WV3283207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0273518Medicaid
WV1376863902Medicaid
KY7100562030Medicaid