Provider Demographics
NPI:1972686160
Name:BULLOCK, PAMELA L (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:L
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:L
Other - Last Name:BELLINGHAUSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1105 PORTLAND AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-2170
Mailing Address - Country:US
Mailing Address - Phone:503-655-2404
Mailing Address - Fax:503-655-1581
Practice Address - Street 1:1105 PORTLAND AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-2170
Practice Address - Country:US
Practice Address - Phone:503-655-2404
Practice Address - Fax:503-655-1581
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20741207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR105791Medicaid
P00691899OtherRR MEDICARE
P00691899OtherRR MEDICARE
ORR140543Medicare PIN
OR105791Medicaid