Provider Demographics
NPI:1073647848
Name:MULLIS EYE INSTITUTE INC
Entity Type:Organization
Organization Name:MULLIS EYE INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:O.
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MULLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-763-6666
Mailing Address - Street 1:1600 JENKS AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4644
Mailing Address - Country:US
Mailing Address - Phone:850-763-6666
Mailing Address - Fax:850-763-6665
Practice Address - Street 1:4320 5TH AVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2182
Practice Address - Country:US
Practice Address - Phone:850-526-7775
Practice Address - Fax:850-763-6665
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MULLIS EYE INSTITUTE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-15
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0027750152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21585Medicare PIN