Provider Demographics
NPI:1003905217
Name:MULLEN, ROBERT DAVID (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DAVID
Last Name:MULLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5635 NE ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-3421
Mailing Address - Country:US
Mailing Address - Phone:503-282-0979
Mailing Address - Fax:
Practice Address - Street 1:5635 NE ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3421
Practice Address - Country:US
Practice Address - Phone:503-282-0979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13715207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR13715OtherSTATE MEDICAL LICENSE
104517Medicare ID - Type Unspecified
C91539Medicare UPIN