Provider Demographics
NPI:1699835017
Name:BULLOCK, MARK DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DANIEL
Last Name:BULLOCK
Suffix:
Gender:M
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:PO BOX 1264
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20725-1264
Mailing Address - Country:US
Mailing Address - Phone:410-740-7030
Mailing Address - Fax:
Practice Address - Street 1:11055 LITTLE PATUXENT PKWY
Practice Address - Street 2:SUITE L-1
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2896
Practice Address - Country:US
Practice Address - Phone:410-740-7030
Practice Address - Fax:410-740-7033
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD41258207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF30790Medicare UPIN