Healthcare Provider Details

I. General information

NPI: 1063464923
Provider Name (Legal Business Name): MARK T MUELLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2745 FORT AMANDA RD
LIMA OH
45805-4805
US

IV. Provider business mailing address

PO BOX 636930
CINCINNATI OH
45263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 419-996-5700
  • Fax: 419-996-5639
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35076924
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: