Provider Demographics
NPI:1104804137
Name:BULLARD, BRANCH RICKEY (MD)
Entity type:Individual
Prefix:DR
First Name:BRANCH
Middle Name:RICKEY
Last Name:BULLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 SW 89TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-8510
Mailing Address - Country:US
Mailing Address - Phone:405-488-0750
Mailing Address - Fax:
Practice Address - Street 1:34 SW 89TH ST STE A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-8510
Practice Address - Country:US
Practice Address - Phone:405-488-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27386207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07403062Medicaid
CO07403062Medicaid
G09308Medicare UPIN