Provider Demographics
NPI:1295772036
Name:BULLIS, DAVID BRYAN (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:BRYAN
Last Name:BULLIS
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:560 W MACPHAIL RD
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4320
Practice Address - Country:US
Practice Address - Phone:410-638-6480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0037491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00187243OtherRAILROAD MEDICARE
MD190581300Medicaid
MD384992ZDDBMedicare PIN
MD384992YVZMedicare PIN
MD328009YWV2Medicare PIN
MD244132YVZMedicare PIN
MDP00187243OtherRAILROAD MEDICARE
MD244132ZDDBMedicare PIN