Basic Information
| Provider Information | |||||||||
| NPI: | 1578907671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BULLOCK | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 S HAVANA ST | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800141618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033384545 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1375 E 20TH AVE | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802055422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033384545 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2013 | ||||||||
| LastUpdateDate: | 05/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | BP10047662 | TX | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 207T00000X | DR.0058235 | CO | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 028905 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER | 9000149868 | 05 | CO | MEDICAID |