Provider Demographics
NPI:1659532182
Name:BULLOCK, NICOLE P (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:P
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 1:2000 PERIMETER PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-8442
Mailing Address - Country:US
Mailing Address - Phone:984-215-4110
Mailing Address - Fax:
Practice Address - Street 1:1120 SE CARY PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7413
Practice Address - Country:US
Practice Address - Phone:919-467-4992
Practice Address - Fax:919-232-5328
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101243677208100000X
NC2009-01450208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA-017OtherTRICARE
VA2181249OtherUHC/MAMSI
VAPAROtherFIRST HEALTH COMMERCIAL
VAPAROtherVA PREMIER HEALTH
VAPAROtherVA HEALTH NETWORK
VA10036799OtherSENTARA/OPTIMA
NC5909717Medicaid
VA1100205OtherUSA MANAGED CARE
VA7285322OtherCIGNA
VA9280154OtherAETNA
VAPAROtherCORVEL/CORCARE
VAPAROtherMULTIPLAN
VA358459OtherANTHEM
NC09717OtherNC BC/BS
VA1659532182Medicaid
VAPAROtherVA HEALTH NETWORK
VA358459OtherANTHEM