Provider Demographics
NPI:1992789317
Name:BULLOCK, LIANA N (OD)
Entity type:Individual
Prefix:DR
First Name:LIANA
Middle Name:N
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-6068
Mailing Address - Country:US
Mailing Address - Phone:253-968-2951
Mailing Address - Fax:253-968-3168
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-4819
Practice Address - Country:US
Practice Address - Phone:253-968-3760
Practice Address - Fax:253-968-3168
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11890152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0035113Medicare ID - Type Unspecified
V07052Medicare UPIN