Provider Demographics
NPI:1649250358
Name:BULLOCK, BRUCE D (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:D
Last Name:BULLOCK
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 1:8 COMMONS ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4651
Mailing Address - Country:US
Mailing Address - Phone:802-770-1805
Mailing Address - Fax:802-773-4876
Practice Address - Street 1:8 COMMONS ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4651
Practice Address - Country:US
Practice Address - Phone:802-770-1805
Practice Address - Fax:802-773-4876
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420008555207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN0388Medicaid
VTOVN0388Medicaid
F31456Medicare UPIN