Provider Demographics
NPI:1700829744
Name:BULLOCH, GERALD F (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:F
Last Name:BULLOCH
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 1:221 W COLORADO BLVD
Mailing Address - Street 2:PAVILION 2 - SUITE 545
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-2363
Mailing Address - Country:US
Mailing Address - Phone:214-941-9100
Mailing Address - Fax:214-941-1949
Practice Address - Street 1:221 W COLORADO BLVD
Practice Address - Street 2:PAVILION 2 - SUITE 545
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2363
Practice Address - Country:US
Practice Address - Phone:214-941-9100
Practice Address - Fax:214-941-1949
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1343207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123334803Medicaid
TX00TT84OtherBC/BS
TX8F9730Medicare PIN
TX00TT84OtherBC/BS
TX080003976Medicare PIN