Basic Information
| Provider Information | |||||||||
| NPI: | 1942217757 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLOCK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017583100 | ||||||||
| FaxNumber: | 6015795240 | ||||||||
| Practice Location | |||||||||
| Address1: | 1238 HIGHWAY 42 | ||||||||
| Address2: | |||||||||
| City: | SUMRALL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017583100 | ||||||||
| FaxNumber: | 6017583008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 12095 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00121120 | 05 | MS | MEDICAID | 1559122 | 01 | MS | AMERICAN ADMIN GROUP | OTHER |