Provider Demographics
NPI:1891727525
Name:BULLOCK, ALFONSO C II (OD)
Entity Type:Individual
Prefix:DR
First Name:ALFONSO
Middle Name:C
Last Name:BULLOCK
Suffix:II
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257B 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-2034
Mailing Address - Country:US
Mailing Address - Phone:201-947-6590
Mailing Address - Fax:631-666-1984
Practice Address - Street 1:261A BROAD AVE.
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650
Practice Address - Country:US
Practice Address - Phone:201-944-3068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV-006870-1152W00000X
NJ27OA00599000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist