Provider Demographics
NPI:1871537712
Name:BULLARD-BERENT, DEBRA BARNITA (MD)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:BARNITA
Last Name:BULLARD-BERENT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 SAN RAFAEL AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-1118
Mailing Address - Country:US
Mailing Address - Phone:505-797-8633
Mailing Address - Fax:505-797-8633
Practice Address - Street 1:1111 SAN RAFAEL AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-1118
Practice Address - Country:US
Practice Address - Phone:505-797-8633
Practice Address - Fax:505-797-8633
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0684207L00000X
CAA77947207L00000X
MI4301074829207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology