Provider Demographics
NPI:1770689101
Name:BULLARD, THERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:BULLARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28360-9494
Mailing Address - Country:US
Mailing Address - Phone:910-272-1230
Mailing Address - Fax:910-738-8230
Practice Address - Street 1:300 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3075
Practice Address - Country:US
Practice Address - Phone:910-272-1230
Practice Address - Fax:910-738-8230
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC99007822084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912273Medicaid
BB3212127OtherDEA
F43080Medicare UPIN
NC8912273Medicaid