Healthcare Provider Details

I. General information

NPI: 1134141401
Provider Name (Legal Business Name): DR. BENNY CARROLL MULLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 03/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 BAGLEY CIR
MARION VA
24354-3126
US

IV. Provider business mailing address

15698 MONTICELLO DR
BRISTOL VA
24202-4110
US

V. Phone/Fax

Practice location:
  • Phone: 276-783-1201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101025318
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101025318
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: