Healthcare Provider Details

I. General information

NPI: 1033422340
Provider Name (Legal Business Name): JUSTIN ANDREW MULLNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 COLONIAL DRIVE FAMILY MEDICINE DEPARTMENT
COLUMBIA SC
29203
US

IV. Provider business mailing address

1222 S ORANGE AVE
ORLANDO FL
32806-1215
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6116
  • Fax: 803-434-8545
Mailing address:
  • Phone: 803-434-6116
  • Fax: 803-434-8545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME148244
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL32987
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: