Basic Information
| Provider Information | |||||||||
| NPI: | 1154303469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MULLEN | ||||||||
| FirstName: | SANFORD | ||||||||
| MiddleName: | ALLEN | ||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 BUTLER ST | ||||||||
| Address2: | PALM BEACH PATHOLOGY PA | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334076006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616590770 | ||||||||
| FaxNumber: | 5618023504 | ||||||||
| Practice Location | |||||||||
| Address1: | 2013 PONCE DELEON AVE | ||||||||
| Address2: | PALM BEACH PATHOLOGY PA | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334076019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616590770 | ||||||||
| FaxNumber: | 5618023504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 05/25/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | ME36784 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 043622400 | 05 | FL | MEDICAID | 14123 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |