Healthcare Provider Details

I. General information

NPI: 1942206578
Provider Name (Legal Business Name): CHARLES D MULLENIX M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

581 E GOLF RD
DES PLAINES IL
60016-2349
US

IV. Provider business mailing address

2440 RAVINE WAY STE 500
GLENVIEW IL
60025-7647
US

V. Phone/Fax

Practice location:
  • Phone: 847-297-2240
  • Fax: 847-297-7270
Mailing address:
  • Phone: 847-297-2240
  • Fax: 847-297-7270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036050116
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: