Healthcare Provider Details

I. General information

NPI: 1134206014
Provider Name (Legal Business Name): MICHAEL MULL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W OLD KEY DR
PERU IN
46970-9057
US

IV. Provider business mailing address

315 W OLD KEY DR
PERU IN
46970-9057
US

V. Phone/Fax

Practice location:
  • Phone: 765-475-6963
  • Fax: 765-475-2833
Mailing address:
  • Phone: 765-475-6963
  • Fax: 765-475-2833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01040504
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: