Provider Demographics
NPI:1932139474
Name:BULLOCK, BRADLEY N (MD)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:N
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 WESTGATE CIRCLE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027
Mailing Address - Country:US
Mailing Address - Phone:615-376-8195
Mailing Address - Fax:615-376-2601
Practice Address - Street 1:1607 WESTGATE CIRCLE
Practice Address - Street 2:SUITE 200
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027
Practice Address - Country:US
Practice Address - Phone:615-376-8195
Practice Address - Fax:615-376-2601
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27418207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3710944Medicaid
TN3825672Medicare ID - Type Unspecified
TN3710944Medicaid