Provider Demographics
NPI:1144295130
Name:BULLOCK, TIMOTHY KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:KEITH
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 1:513 BROOKWOOD BLVD
Mailing Address - Street 2:SUITE 501
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-6862
Mailing Address - Country:US
Mailing Address - Phone:205-930-8010
Mailing Address - Fax:205-930-8014
Practice Address - Street 1:860 MONTCLAIR RD
Practice Address - Street 2:SUITE 758
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35213-1923
Practice Address - Country:US
Practice Address - Phone:205-930-8020
Practice Address - Fax:205-930-8024
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL24255208600000X, 193400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No193400000XGroupSingle Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALO20052623Medicare PIN
ALH59949Medicare UPIN
AL51507661Medicare PIN