Healthcare Provider Details

I. General information

NPI: 1417037755
Provider Name (Legal Business Name): JOHN M MULAWKA III DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6763 ERIE ROAD RT 5
DERBY NY
14047
US

IV. Provider business mailing address

6763 ERIE ROAD RT 5
DERBY NY
14047
US

V. Phone/Fax

Practice location:
  • Phone: 716-947-2222
  • Fax: 716-947-2223
Mailing address:
  • Phone: 716-947-2222
  • Fax: 716-947-2223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number224453
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: