Basic Information
| Provider Information | |||||||||
| NPI: | 1437157047 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARTIN, WEDEL & BULLARD, O.D., P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY EYE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 839 N NOLAN RIVER RD | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760337001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176452411 | ||||||||
| FaxNumber: | 8176453447 | ||||||||
| Practice Location | |||||||||
| Address1: | 4460 E HIGHWAY 287 STE A | ||||||||
| Address2: | |||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760657031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727758000 | ||||||||
| FaxNumber: | 9727758003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| 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 | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 81036Q | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 80183Q | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 80286Q | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 80182Q | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 0065DG | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |