Provider Demographics
NPI:1144713652
Name:BULLARD, RAEONDA (MD)
Entity type:Individual
Prefix:
First Name:RAEONDA
Middle Name:
Last Name:BULLARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RAEONDA
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6095 PROFESSIONAL PKWY STE A210
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-5611
Mailing Address - Country:US
Mailing Address - Phone:770-949-4188
Mailing Address - Fax:770-949-1614
Practice Address - Street 1:6095 PROFESSIONAL PKWY STE A210
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5611
Practice Address - Country:US
Practice Address - Phone:770-949-4188
Practice Address - Fax:770-949-1614
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010079207V00000X
GA93170207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300034164AMedicaid