Provider Demographics
NPI:1649241001
Name:BULLOCK, LINDA M (DO)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:M
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 MONTGOMERY AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:PENN VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19072-1548
Mailing Address - Country:US
Mailing Address - Phone:610-668-7992
Mailing Address - Fax:610-668-7991
Practice Address - Street 1:915 MONTGOMERY AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:PENN VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19072-1548
Practice Address - Country:US
Practice Address - Phone:610-668-7992
Practice Address - Fax:610-668-7991
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008246L207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G29071Medicare UPIN
PA232359401OtherMAIN LINE HEALTHCARE
G29071Medicare UPIN
PA001604974Medicaid