Provider Demographics
NPI:1306801766
Name:BULLARD, TIMOTHY C (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:C
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4560 ADMIRALTY WAY STE 100
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5424
Practice Address - Country:US
Practice Address - Phone:108-273-7003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64738207P00000X, 207Q00000X
IN01051619207P00000X
MI4301082809207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A647380Medicaid
MI1306801766OtherBC BS MI
MI1306801766Medicaid
CA930098046OtherRAILROAD
CA00A647380Medicaid
MI1306801766OtherBC BS MI
MI1306801766Medicaid
CA00A647386Medicare PIN
CA00A647387Medicare PIN