Provider Demographics
NPI:1316171580
Name:BULLOCK, MATTHEW WAYNE (DO)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WAYNE
Last Name:BULLOCK
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1249 15TH ST STE 4093
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3662
Mailing Address - Country:US
Mailing Address - Phone:304-691-8722
Mailing Address - Fax:
Practice Address - Street 1:1600 MEDICAL CENTER DR STE G500
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3659
Practice Address - Country:US
Practice Address - Phone:304-691-1262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00364207XS0114X
WV3280207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCJ116AMedicare PIN