Basic Information
| Provider Information | |||||||||
| NPI: | 1679581870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLEN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MULLEN | ||||||||
| OtherFirstName: | MARK | ||||||||
| OtherMiddleName: | JAY | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1648 HUNTINGDON PIKE | ||||||||
| Address2: | MEDICAL STAFF OFFICE 1ST FLR | ||||||||
| City: | MEADOWBROOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190468001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159383450 | ||||||||
| FaxNumber: | 2159383829 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 BUSTLETON PIKE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FEASTERVILLE TREVOSE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190536446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154640770 | ||||||||
| FaxNumber: | 2675790720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD0402071E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.