Provider Demographics
NPI:1790429140
Name:BULLOCH, ASHLEY MICHELLE
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MICHELLE
Last Name:BULLOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:DEVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1541 KINGS HWY
Mailing Address - Street 2:ATTN: PAYORCREDENTIALING
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-626-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA346459207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine