Basic Information
| Provider Information | |||||||||
| NPI: | 1336308444 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BULLOCK | ||||||||
| FirstName: | SMITHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 909 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402010909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025854802 | ||||||||
| FaxNumber: | 5025891256 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 S FLOYD ST | ||||||||
| Address2: | SUITE 602 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025854802 | ||||||||
| FaxNumber: | 5025891256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2008 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | 45511 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 7100224090 | 05 | KY | MEDICAID |