Healthcare Provider Details

I. General information

NPI: 1407875800
Provider Name (Legal Business Name): DOUGLAS MULLER P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HSC LEVEL 4 RM 080
STONY BROOK NY
11794-0001
US

IV. Provider business mailing address

P.O. BOX 1559
STONY BROOK NY
11790
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2478
  • Fax: 631-444-3919
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number006663
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: