Provider Demographics
NPI:1508872417
Name:BULLARD, STEPHEN MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MARK
Last Name:BULLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1369 RAHR AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-5363
Mailing Address - Country:US
Mailing Address - Phone:920-232-9932
Mailing Address - Fax:
Practice Address - Street 1:1540 LYON DR
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-5069
Practice Address - Country:US
Practice Address - Phone:920-727-4946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38647-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIG40755Medicare UPIN