Provider Demographics
NPI:1356547434
Name:BULLOCK, MALTON JOSEPH JR (MD)
Entity type:Individual
Prefix:DR
First Name:MALTON
Middle Name:JOSEPH
Last Name:BULLOCK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4423 PINE PARK DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-6922
Mailing Address - Country:US
Mailing Address - Phone:225-924-4488
Mailing Address - Fax:225-924-1531
Practice Address - Street 1:4423 PINE PARK DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-6922
Practice Address - Country:US
Practice Address - Phone:225-924-4488
Practice Address - Fax:225-924-1531
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA04483R207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1195421Medicaid
LA1195421Medicaid
LA50128Medicare ID - Type Unspecified