Healthcare Provider Details

I. General information

NPI: 1790913010
Provider Name (Legal Business Name): KENNETH LYNN MULDREW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

1504 TAUB LOOP
HOUSTON TX
77030-1608
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-1540
  • Fax:
Mailing address:
  • Phone: 713-873-2468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License NumberMD37080
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207ZM0300X
TaxonomyMedical Microbiology Physician
License NumberMD37080
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberMD37080
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License NumberR0286
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: