Provider Demographics
NPI:1366510703
Name:BULLOCK, EDDYE J (MD)
Entity type:Individual
Prefix:DR
First Name:EDDYE
Middle Name:J
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2101 EAST JEFFERSON STREET
Mailing Address - Street 2:PPQA MEDICARE COMPLIANCE UNIT 6 WEST
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:7141 SECURITY BLVD
Practice Address - Street 2:KASIER PERMANENTE WOODLAWN MEDICAL CENTER
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-1811
Practice Address - Country:US
Practice Address - Phone:443-663-6000
Practice Address - Fax:443-663-6215
Is Sole Proprietor?:No
Enumeration Date:2006-12-02
Last Update Date:2021-06-07
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Provider Licenses
StateLicense IDTaxonomies
MDD57214207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H43383Medicare UPIN
S883K665Medicare ID - Type Unspecified