Provider Demographics
NPI:1851452296
Name:BULLARD, KENNETH PENN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:PENN
Last Name:BULLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 CHARTER PLACE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-5503
Mailing Address - Country:US
Mailing Address - Phone:704-364-2358
Mailing Address - Fax:
Practice Address - Street 1:1225 CHARTER PLACE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5503
Practice Address - Country:US
Practice Address - Phone:704-364-2358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15028208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC19723OtherBLUE CROSS BLUE SHIELD
SC360677Medicaid
NC8919723Medicaid
NC19723OtherBLUE CROSS BLUE SHIELD
NC8919723Medicaid