Provider Demographics
NPI:1437108685
Name:BULLOCK, CARMEN N (O D)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:N
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 KINGSVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-2734
Mailing Address - Country:US
Mailing Address - Phone:317-839-0713
Mailing Address - Fax:317-837-4093
Practice Address - Street 1:2373 E MAIN ST
Practice Address - Street 2:WAL-MART VISION CENTER
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-2717
Practice Address - Country:US
Practice Address - Phone:317-839-0713
Practice Address - Fax:317-837-4093
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002990152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200240510Medicaid
IN200240510Medicaid
INU78460Medicare UPIN