Basic Information
| Provider Information | |||||||||
| NPI: | 1245238815 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARTIN, WEDEL & BULLARD, O.D., P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CLEBURNE EYE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 839 N NOLAN RIVER RD | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760337001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176452411 | ||||||||
| FaxNumber: | 8176453447 | ||||||||
| Practice Location | |||||||||
| Address1: | 839 N NOLAN RIVER RD | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760337001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176452411 | ||||||||
| FaxNumber: | 8176453447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BULLARD | ||||||||
| AuthorizedOfficialFirstName: | HEATH | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8176452411 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 80181Q | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 80182Q | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 0065DG | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 81036Q | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 019132201 | 05 | TX | MEDICAID | 80286Q | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 80183Q | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |