Basic Information
| Provider Information | |||||||||
| NPI: | 1598770927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLOCK | ||||||||
| FirstName: | CINDY | ||||||||
| MiddleName: | ELISE | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 MADISON ST | ||||||||
| Address2: | SUITE 901 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062648100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1401 S LAVENTURE RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982746033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604242400 | ||||||||
| FaxNumber: | 3604242418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 12/30/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | PO60058024 | WA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 06926029 | 05 | NJ | MEDICAID |