=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033422340
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN ANDREW MULLNER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2010
-----------------------------------------------------
Last Update Date | 12/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3209 COLONIAL DRIVE FAMILY MEDICINE DEPARTMENT
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-434-6116
-----------------------------------------------------
Fax | 803-434-8545
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1222 S ORANGE AVE
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-434-6116
-----------------------------------------------------
Fax | 803-434-8545
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | ME148244
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | LL32987
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------