Healthcare Provider Details

I. General information

NPI: 1063434538
Provider Name (Legal Business Name): JOHN MULLINS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2251 WAR ADMIRAL WAY SUITE 125
LEXINGTON KY
40509
US

IV. Provider business mailing address

2251 WAR ADMIRAL WAY SUITE 125
LEXINGTON KY
40509
US

V. Phone/Fax

Practice location:
  • Phone: 859-335-9041
  • Fax: 859-335-9072
Mailing address:
  • Phone: 330-864-8900
  • Fax: 330-869-8924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number30990
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: