Healthcare Provider Details

I. General information

NPI: 1689105504
Provider Name (Legal Business Name): GREGORY R MULLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S ORANGE AVE STE 228
LIVINGSTON NJ
07039-5817
US

IV. Provider business mailing address

200 S ORANGE AVE STE 228
LIVINGSTON NJ
07039-5817
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number25MA11814000
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number312602
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: