Provider Demographics
NPI:1720703044
Name:BULLOCKS-FOX, BRENDA A
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:A
Last Name:BULLOCKS-FOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6524 E 44TH PL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-3508
Mailing Address - Country:US
Mailing Address - Phone:317-833-2470
Mailing Address - Fax:
Practice Address - Street 1:6524 E 44TH PL
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-3508
Practice Address - Country:US
Practice Address - Phone:317-833-2470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN015296207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN853599761Medicaid