Provider Demographics
NPI:1922150978
Name:BULLARD, MIRIAM K (MD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:K
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 1:5528 PACHECO BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:PACHECO
Mailing Address - State:CA
Mailing Address - Zip Code:94553-5126
Mailing Address - Country:US
Mailing Address - Phone:925-363-8170
Mailing Address - Fax:
Practice Address - Street 1:1411 E 31ST ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-1018
Practice Address - Country:US
Practice Address - Phone:510-437-4965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79511208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A795110Medicaid
CA00A795110Medicaid
CAH06010Medicare UPIN