Provider Demographics
NPI:1184762213
Name:BULLARD, KAY S (OD)
Entity type:Individual
Prefix:
First Name:KAY
Middle Name:S
Last Name:BULLARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KAY
Other - Middle Name:SCOTT
Other - Last Name:BULLARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:CHERAW
Mailing Address - State:SC
Mailing Address - Zip Code:29520-1209
Mailing Address - Country:US
Mailing Address - Phone:843-537-3641
Mailing Address - Fax:843-537-3646
Practice Address - Street 1:703 MARKET ST
Practice Address - Street 2:
Practice Address - City:CHERAW
Practice Address - State:SC
Practice Address - Zip Code:29520-1209
Practice Address - Country:US
Practice Address - Phone:843-537-3641
Practice Address - Fax:843-537-3646
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC840152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD08409Medicaid
SCAA57629606Medicare PIN
SCD08409Medicaid