Provider Demographics
NPI:1023001245
Name:MULLEN, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2558
Mailing Address - Country:US
Mailing Address - Phone:607-770-0025
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:1290 UPPER FRONT ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-1043
Practice Address - Country:US
Practice Address - Phone:607-722-3417
Practice Address - Fax:607-722-7610
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01657258Medicaid
NY54474QMedicare PIN
G34153Medicare UPIN