Healthcare Provider Details

I. General information

NPI: 1124005533
Provider Name (Legal Business Name): KEVIN MICHAEL MCMULLEN MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11011 HEFNER POINTE DR SUITE A
OKLAHOMA CITY OK
73120-5005
US

IV. Provider business mailing address

PO BOX 26525 SECTION 47
OKLAHOMA CITY OK
73126-0525
US

V. Phone/Fax

Practice location:
  • Phone: 405-749-8346
  • Fax: 405-749-8349
Mailing address:
  • Phone: 405-749-8346
  • Fax: 405-749-8349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number17646
License Number StateOK

VIII. Authorized Official

Name: KEVIN MICHAEL MCMULLEN
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 405-749-8346