Provider Demographics
NPI:1902912793
Name:BULLOCK, NEAL M (DPM)
Entity Type:Individual
Prefix:
First Name:NEAL
Middle Name:M
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17013 PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1003
Mailing Address - Country:US
Mailing Address - Phone:954-450-4200
Mailing Address - Fax:954-450-4237
Practice Address - Street 1:17013 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1003
Practice Address - Country:US
Practice Address - Phone:954-450-4200
Practice Address - Fax:954-450-4237
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO0002571213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65515OtherBLUE CROSS BLUE SHIELD
FL390394000Medicaid
FL65515AMedicare ID - Type Unspecified
FL1298140001Medicare NSC
FLU68052Medicare UPIN