Provider Demographics
NPI:1598770927
Name:BULLOCK, CINDY ELISE (DPM)
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:ELISE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 MADISON ST
Mailing Address - Street 2:SUITE 901
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1172
Mailing Address - Country:US
Mailing Address - Phone:206-264-8100
Mailing Address - Fax:
Practice Address - Street 1:1401 S LAVENTURE RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-6033
Practice Address - Country:US
Practice Address - Phone:360-424-2400
Practice Address - Fax:360-424-2418
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO60058024213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ06926029Medicaid
348431703Medicare ID - Type Unspecified
NJ06926029Medicaid