Provider Demographics
NPI:1366076556
Name:BULLARD, EDWIN PETER (BCO, BADO)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:PETER
Last Name:BULLARD
Suffix:
Gender:M
Credentials:BCO, BADO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 S GARNETT RD STE 302
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5218
Mailing Address - Country:US
Mailing Address - Phone:918-664-6544
Mailing Address - Fax:918-664-0668
Practice Address - Street 1:4606 S GARNETT RD STE 302
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5218
Practice Address - Country:US
Practice Address - Phone:918-664-6544
Practice Address - Fax:918-664-0668
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist