Provider Demographics
NPI:1760673917
Name:BULLEN, LAURI WILKES (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURI
Middle Name:WILKES
Last Name:BULLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAURI
Other - Middle Name:ELLEN
Other - Last Name:WILKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 FAIRVIEW PARK DR STE 300
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2567
Mailing Address - Country:US
Mailing Address - Phone:478-246-4304
Mailing Address - Fax:478-246-4282
Practice Address - Street 1:104 FAIRVIEW PARK DR STE 300
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2567
Practice Address - Country:US
Practice Address - Phone:478-246-4304
Practice Address - Fax:478-246-4282
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30627207V00000X
GA86978207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC306270Medicaid