Provider Demographics
NPI:1790121499
Name:BULL, LISA MASK (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MASK
Last Name:BULL
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 1:9245 S MINGO RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5793
Mailing Address - Country:US
Mailing Address - Phone:918-492-8980
Mailing Address - Fax:918-495-0607
Practice Address - Street 1:9245 S MINGO RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133
Practice Address - Country:US
Practice Address - Phone:918-492-8980
Practice Address - Fax:918-495-0607
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK30038207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program