Provider Demographics
NPI:1700923778
Name:BULLARD, DANNY WAYNE
Entity Type:Individual
Prefix:
First Name:DANNY
Middle Name:WAYNE
Last Name:BULLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:OK
Mailing Address - Zip Code:74572-0188
Mailing Address - Country:US
Mailing Address - Phone:580-927-5158
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 24
Practice Address - Street 2:48 HIGHWAY
Practice Address - City:TUPELO
Practice Address - State:OK
Practice Address - Zip Code:74572-9706
Practice Address - Country:US
Practice Address - Phone:580-927-5158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor