Provider Demographics
NPI:1700808672
Name:BULL, KENNETH HAROLD (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:HAROLD
Last Name:BULL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3500 COMANCHE RD NE
Mailing Address - Street 2:BLDG E6
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-4546
Mailing Address - Country:US
Mailing Address - Phone:505-881-8666
Mailing Address - Fax:505-881-3261
Practice Address - Street 1:3500 COMANCHE RD NE
Practice Address - Street 2:BLDG E6
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4546
Practice Address - Country:US
Practice Address - Phone:505-881-8666
Practice Address - Fax:505-881-3261
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM73-992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM04556Medicaid
NM347735502OtherMEDICARE PTAN
NM04556Medicaid