Provider Demographics
NPI:1790749943
Name:SHAW-BULLOCK, ROSE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARIE
Last Name:SHAW-BULLOCK
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 1:400 W PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:N LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-2146
Mailing Address - Country:US
Mailing Address - Phone:501-771-7717
Mailing Address - Fax:501-771-0550
Practice Address - Street 1:400 W PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:N LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-2146
Practice Address - Country:US
Practice Address - Phone:501-771-7717
Practice Address - Fax:501-771-0550
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0873207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR132896001Medicaid
AR132896001Medicaid
AR5K549Medicare ID - Type Unspecified