Basic Information
| Provider Information | |||||||||
| NPI: | 1699202275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLER | ||||||||
| FirstName: | IMELDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 MILLERBROOK LN | ||||||||
| Address2: | |||||||||
| City: | COPAKE FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125175409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189296217 | ||||||||
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| Practice Location | |||||||||
| Address1: | NAVAL MEDICAL CENTER 34800 BOB WILSON DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921340001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195325998 | ||||||||
| FaxNumber: | 6195325507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2017 | ||||||||
| LastUpdateDate: | 05/15/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | Y | Other Service Providers | Military Health Care Provider |
ID Information
| ID | Type | State | Issuer | Description | VAD0000 | 05 | CA | MEDICAID |