Provider Demographics
NPI:1124005533
Name:KEVIN MICHAEL MCMULLEN MD PLLC
Entity Type:Organization
Organization Name:KEVIN MICHAEL MCMULLEN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCMULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-749-8346
Mailing Address - Street 1:PO BOX 26525
Mailing Address - Street 2:SECTION 47
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-0525
Mailing Address - Country:US
Mailing Address - Phone:405-749-8346
Mailing Address - Fax:405-749-8349
Practice Address - Street 1:11011 HEFNER POINTE DR
Practice Address - Street 2:SUITE A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-5005
Practice Address - Country:US
Practice Address - Phone:405-749-8346
Practice Address - Fax:405-749-8349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK176462086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100522049Medicare PIN
DA7559Medicare PIN