Provider Demographics
NPI:1598394603
Name:BULLOCK, DANIELLE SAMONE (MD)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:SAMONE
Last Name:BULLOCK
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 1:15105 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-3719
Mailing Address - Country:US
Mailing Address - Phone:216-800-8020
Mailing Address - Fax:216-830-7652
Practice Address - Street 1:15105 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-3719
Practice Address - Country:US
Practice Address - Phone:216-800-8020
Practice Address - Fax:216-830-7652
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.149097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine