Provider Demographics
NPI:1477547784
Name:BULLOCK, ANNE CONSTANIA (MD)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:CONSTANIA
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 SANDY PLAINS ROAD
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:619 S 8TH ST STE 301
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4260
Practice Address - Country:US
Practice Address - Phone:770-229-6072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032140207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00569698BMedicaid
GA360003154/CM0845OtherRAILROAD MEDICARE
GA360003154/CM0845OtherRAILROAD MEDICARE
GA36BDBBKMedicare ID - Type Unspecified