Healthcare Provider Details

I. General information

NPI: 1558688663
Provider Name (Legal Business Name): THOMAS MATTHEW MULLIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HIGHWAY 65 S
MORA MN
55051-1899
US

IV. Provider business mailing address

301 HIGHWAY 65 S
MORA MN
55051-1899
US

V. Phone/Fax

Practice location:
  • Phone: 320-679-1313
  • Fax: 320-674-9060
Mailing address:
  • Phone: 320-679-1313
  • Fax: 320-674-9060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number54203
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: