Healthcare Provider Details

I. General information

NPI: 1164982880
Provider Name (Legal Business Name): KIRAN MULLUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER BOULEVARD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

1 JONATHAN AVE
MILLBURY MA
01527-3950
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-4479
  • Fax:
Mailing address:
  • Phone: 508-450-1534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0101288534
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101288534
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: