Provider Demographics
NPI:1104824606
Name:MULLEN, EDWARD E (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:E
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:PO BOX 5670
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11802-5670
Mailing Address - Country:US
Mailing Address - Phone:516-632-3370
Mailing Address - Fax:516-336-2930
Practice Address - Street 1:1 HEALTHY WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1551
Practice Address - Country:US
Practice Address - Phone:516-632-3303
Practice Address - Fax:516-336-2930
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172604174400000X
NY172604-12085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1466513Medicaid
NY01465513Medicaid
NYE48970Medicare UPIN
NY02202GMedicare ID - Type UnspecifiedMEDICARE
NY98H211Medicare PIN