Healthcare Provider Details

I. General information

NPI: 1235182221
Provider Name (Legal Business Name): SAMIR MULLICK MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4267 W FOND DU LAC AVE
MILWAUKEE WI
53216-3527
US

IV. Provider business mailing address

4267 W FOND DU LAC AVE
MILWAUKEE WI
53216-3527
US

V. Phone/Fax

Practice location:
  • Phone: 414-873-3440
  • Fax:
Mailing address:
  • Phone: 414-873-3440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number38382
License Number StateWI

VIII. Authorized Official

Name: SAMIR MULLICK
Title or Position: OWNER
Credential: MD
Phone: 414-873-3440