Basic Information
| Provider Information | |||||||||
| NPI: | 1033101712 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLOCK | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | REID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4747 E CAMP LOWELL DR | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857121256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207315540 | ||||||||
| FaxNumber: | 5207315540 | ||||||||
| Practice Location | |||||||||
| Address1: | 4582 N 1ST AVE | ||||||||
| Address2: | SUITE 170 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857188603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203186035 | ||||||||
| FaxNumber: | 5207959953 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 09/10/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 16618 | AZ | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 277807 | 05 | AZ | MEDICAID |