Provider Demographics
NPI:1053668558
Name:WALTER R. MULLIN, M.D, P.A
Entity Type:Organization
Organization Name:WALTER R. MULLIN, M.D, P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:R
Authorized Official - Last Name:MULLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-325-1441
Mailing Address - Street 1:9155 S DADELAND BLVD
Mailing Address - Street 2:SUITE 1404
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-2737
Mailing Address - Country:US
Mailing Address - Phone:305-325-1441
Mailing Address - Fax:305-670-0770
Practice Address - Street 1:9155 S. DADELAND BLVD
Practice Address - Street 2:SUITE 1404
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-2739
Practice Address - Country:US
Practice Address - Phone:305-325-1441
Practice Address - Fax:305-670-0770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-14
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME16284OtherSTATE LICENSE #
FLD60104Medicare UPIN