Provider Demographics
NPI:1083688923
Name:MUSHLIN, GENNADY (MD)
Entity Type:Individual
Prefix:
First Name:GENNADY
Middle Name:
Last Name:MUSHLIN
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 1:4235 CANYON TRAILS DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-2705
Mailing Address - Country:US
Mailing Address - Phone:940-691-9722
Mailing Address - Fax:
Practice Address - Street 1:149 HART ST
Practice Address - Street 2:82 MEDICAL GROUP
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311-3477
Practice Address - Country:US
Practice Address - Phone:940-676-6855
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22575207Q00000X
TXL5066207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN