Provider Demographics
NPI:1730471293
Name:BULLOCK, DANIELLE RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:RENEE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DANIELLE
Other - Middle Name:RENEE
Other - Last Name:BRUECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2450 RIVERSIDE AVE
Mailing Address - Street 2:M663 EAST BUILDING
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1450
Mailing Address - Country:US
Mailing Address - Phone:612-626-4598
Mailing Address - Fax:612-626-6905
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:M663 EAST BUILDING
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:612-626-4598
Practice Address - Fax:612-626-6905
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN57986208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics