Healthcare Provider Details

I. General information

NPI: 1912906462
Provider Name (Legal Business Name): TARUN MULLICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 S DOBSON RD STE 101
CHANDLER AZ
85224-5603
US

IV. Provider business mailing address

2631 WILLIAMSBURG AVE SUITE 301
GENEVA IL
60134-1101
US

V. Phone/Fax

Practice location:
  • Phone: 480-728-4981
  • Fax:
Mailing address:
  • Phone: 630-232-2025
  • Fax: 630-232-2780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number036108726
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number35.143072
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number4301502257
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number58745
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: