Provider Demographics
NPI:1417926965
Name:BULLARD, GUINEVERE JOHNSON (MD)
Entity Type:Individual
Prefix:
First Name:GUINEVERE
Middle Name:JOHNSON
Last Name:BULLARD
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 1:4240 SUN N LAKE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-1944
Mailing Address - Country:US
Mailing Address - Phone:863-402-2229
Mailing Address - Fax:863-402-1209
Practice Address - Street 1:4240 SUN N LAKE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-1944
Practice Address - Country:US
Practice Address - Phone:863-402-2229
Practice Address - Fax:863-402-1209
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100722207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280280500Medicaid
FL280280500Medicaid