Provider Demographics
NPI:1184625865
Name:BULLOCK, OLIVER C (DO)
Entity type:Individual
Prefix:
First Name:OLIVER
Middle Name:C
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 W CAMBRIA ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132-2632
Mailing Address - Country:US
Mailing Address - Phone:215-578-3300
Mailing Address - Fax:215-578-3335
Practice Address - Street 1:2100 W CAMBRIA ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-2632
Practice Address - Country:US
Practice Address - Phone:215-578-3300
Practice Address - Fax:215-578-3335
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004271L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000655010Medicaid
PA105758E7LMedicare PIN
D77390Medicare UPIN