Healthcare Provider Details

I. General information

NPI: 1891998498
Provider Name (Legal Business Name): JOHN LAIRD MCMULLEN III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2007
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E DIXIE AVE SUITE 104
LEESBURG FL
34748-7699
US

IV. Provider business mailing address

734 N 3RD ST SUITE 115
LEESBURG FL
34748-5285
US

V. Phone/Fax

Practice location:
  • Phone: 352-365-2583
  • Fax: 352-728-6749
Mailing address:
  • Phone: 352-365-2583
  • Fax: 352-728-6749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number93848
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License NumberME93848
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number93849
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207RM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Internal Medicine Physician
License Number93848
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: