Healthcare Provider Details

I. General information

NPI: 1588752307
Provider Name (Legal Business Name): TIMOTHY I MULLIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 12/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W PARADISE DR ORTHOPAEDIC SURGERY
WEST BEND WI
53095-9795
US

IV. Provider business mailing address

1700 W PARADISE DR ORTHOPAEDIC SURGERY
WEST BEND WI
53095-9795
US

V. Phone/Fax

Practice location:
  • Phone: 262-334-3451
  • Fax: 262-326-2964
Mailing address:
  • Phone: 262-334-3451
  • Fax: 262-326-2964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number48489 - 20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: