Provider Demographics
NPI:1598935249
Name:NEAL M BULLOCK DPM PA
Entity Type:Organization
Organization Name:NEAL M BULLOCK DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NEAL
Authorized Official - Middle Name:M
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:954-450-4200
Mailing Address - Street 1:17013 PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1003
Mailing Address - Country:US
Mailing Address - Phone:954-450-4200
Mailing Address - Fax:954-450-4237
Practice Address - Street 1:17013 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1003
Practice Address - Country:US
Practice Address - Phone:954-450-4200
Practice Address - Fax:954-450-4237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2571213E00000X
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390394000Medicaid
FL1298140001Medicare NSC