Provider Demographics
NPI:1255440020
Name:BULLOCK, GINA M (DPM)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3508 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1821
Mailing Address - Country:US
Mailing Address - Phone:503-282-8777
Mailing Address - Fax:503-282-8853
Practice Address - Street 1:3508 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1821
Practice Address - Country:US
Practice Address - Phone:503-282-8777
Practice Address - Fax:503-282-8853
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00244213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR083431Medicaid
ORBB3746748OtherDEA #
ORBB3746748OtherDEA #
OR083431Medicaid
ORR139834Medicare PIN
ORR137533Medicare PIN