Healthcare Provider Details

I. General information

NPI: 1720408479
Provider Name (Legal Business Name): MATTHEW TRAVIS MULLANE MD MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 NE IRVING AVE
BEND OR
97701-4738
US

IV. Provider business mailing address

62472 QUAIL RIDGE RD
BEND OR
97701-9553
US

V. Phone/Fax

Practice location:
  • Phone: 541-255-1530
  • Fax: 541-219-5356
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License NumberMD189798
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberMD189798
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0056225
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD61336231
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD189798
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: