Provider Demographics
NPI:1912058272
Name:BULLOCK, DAVID SHIRLEY (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:SHIRLEY
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 1:140 NEWCOMB AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:KY
Mailing Address - Zip Code:40456-2728
Mailing Address - Country:US
Mailing Address - Phone:606-256-5176
Mailing Address - Fax:606-256-4401
Practice Address - Street 1:140 NEWCOMB AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:KY
Practice Address - Zip Code:40456-2728
Practice Address - Country:US
Practice Address - Phone:606-256-5176
Practice Address - Fax:606-256-4401
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39587207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
611064744OtherTAX ID
P00333608OtherRAIL ROAD MEDICARE
11606348OtherCAQH
KY64114101Medicaid
000000495658OtherANTHEM BC BS
1230533OtherCHA
1230533OtherCHA
KY64114101Medicaid
BB9068900OtherDEA