MEDICARE: MILTON GAYLE MULLANAX M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	D1750	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	072055635	OTHER	TX	TEXAS RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86620X	OTHER	TX	BCBS
3	4325609	OTHER	TX	AETNA PROVIDER NUMBER

General Provider Information

NPI Number	:	1700932076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MILTON GAYLE MULLANAX M.D.

Provider Business Mailing Address
First Line	:	715 N FIELDER RD
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76012-4695
Country	:	US
Telephone Number	:	817-261-1626
Fax Number	:

Provider Business Practice Location Address
First Line	:	715 N FIELDER RD
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76012-4695
Country	:	US
Telephone Number	:	817-261-1626
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	08/07/2008

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