Healthcare Provider Details

I. General information

NPI: 1104227628
Provider Name (Legal Business Name): OLIN MAULDIN M.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4217 BAYMEADOWS RD SUITE 3
JACKSONVILLE FL
32217-4676
US

IV. Provider business mailing address

4217 BAYMEADOWS RD SUITE 3
JACKSONVILLE FL
32217-4676
US

V. Phone/Fax

Practice location:
  • Phone: 904-332-7431
  • Fax: 904-332-7408
Mailing address:
  • Phone: 904-332-7431
  • Fax: 904-332-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME54094
License Number StateFL

VIII. Authorized Official

Name: WENDY C LU
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 904-332-7431