Provider Demographics
NPI:1497216816
Name:BULLOCH, LANDON RAE (MD)
Entity Type:Individual
Prefix:
First Name:LANDON
Middle Name:RAE
Last Name:BULLOCH
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 1:823 S CHURCH ST APT 1439
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-4749
Mailing Address - Country:US
Mailing Address - Phone:864-940-9579
Mailing Address - Fax:
Practice Address - Street 1:1025 MOREHEAD MEDICAL DR STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2966
Practice Address - Country:US
Practice Address - Phone:704-446-2772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0071207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery