Provider Demographics
NPI:1760496244
Name:BULLARD, RICKEY H (DPM)
Entity Type:Individual
Prefix:DR
First Name:RICKEY
Middle Name:H
Last Name:BULLARD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801
Mailing Address - Country:US
Mailing Address - Phone:662-844-4766
Mailing Address - Fax:662-680-6997
Practice Address - Street 1:1902 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801
Practice Address - Country:US
Practice Address - Phone:662-844-4766
Practice Address - Fax:662-680-6997
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80058213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS19928Medicaid
MS19928Medicaid
T20847Medicare UPIN