Provider Demographics
NPI:1073574562
Name:MCMULLEN, BRUCE ROGER (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ROGER
Last Name:MCMULLEN
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 1:1122 SOUTH CLIFTON
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-2913
Mailing Address - Country:US
Mailing Address - Phone:316-682-5012
Mailing Address - Fax:316-652-9510
Practice Address - Street 1:1122 SOUTH CLIFTON
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2913
Practice Address - Country:US
Practice Address - Phone:316-682-5012
Practice Address - Fax:316-652-9510
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-01
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0418744207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0004084117OtherAETNA INS
KS100199260BMedicaid
110004044OtherPALMETTO GBA RAILROAD MED
KS100199260BMedicaid