Provider Demographics
NPI:1699810507
Name:BULLOCK, TRAVIS L (MD)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:L
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:TRAVIS
Other - Last Name:BULLOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12855 N. FORTY DR.
Mailing Address - Street 2:STE 375
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-567-6071
Mailing Address - Fax:314-567-3321
Practice Address - Street 1:12855 N 40 DR STE 350
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8669
Practice Address - Country:US
Practice Address - Phone:314-567-6071
Practice Address - Fax:314-567-3321
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007030776208800000X
IL036113441208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNPENDINGMedicaid
MNPENDINGMedicare ID - Type Unspecified
MNPENDINGMedicaid