Healthcare Provider Details

I. General information

NPI: 1235657313
Provider Name (Legal Business Name): BRENDAN THOMAS MULLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST MAIL STOP 800744
CHARLOTTESVILLE VA
22908-0816
US

IV. Provider business mailing address

1215 LEE ST MAIL STOP 800744
CHARLOTTESVILLE VA
22908-0816
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-1931
  • Fax: 434-243-5770
Mailing address:
  • Phone: 434-924-1931
  • Fax: 434-243-5770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: