Provider Demographics
NPI:1710079736
Name:BULLIS, KENT (MD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:
Last Name:BULLIS
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 1:110 HO PLZ
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14853-3102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 HO PLZ
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14853-3102
Practice Address - Country:US
Practice Address - Phone:607-255-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1034097207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND95444Medicare UPIN