Provider Demographics
NPI:1942217757
Name:BULLOCK, JOHN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:BULLOCK
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-758-3100
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:1238 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:SUMRALL
Practice Address - State:MS
Practice Address - Zip Code:39482
Practice Address - Country:US
Practice Address - Phone:601-758-3100
Practice Address - Fax:601-758-3008
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121120Medicaid
MS1559122OtherAMERICAN ADMIN GROUP
080144487OtherRAILROAD MEDICARE
E20742Medicare UPIN
MS080003128Medicare PIN