Provider Demographics
NPI:1922194000
Name:BULLOCK, SELAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SELAM
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SELAMAWIT
Other - Middle Name:
Other - Last Name:GHEBREMEDHIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:23 SUNNYBROOK RD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1855
Mailing Address - Country:US
Mailing Address - Phone:919-250-3478
Mailing Address - Fax:919-250-6272
Practice Address - Street 1:23 SUNNYBROOK RD
Practice Address - Street 2:SUITE 116
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1855
Practice Address - Country:US
Practice Address - Phone:919-250-3478
Practice Address - Fax:919-250-6272
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200201084208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905271Medicaid
NC5905271Medicaid