Provider Demographics
NPI:1154303469
Name:MULLEN, SANFORD ALLEN JR (MD)
Entity Type:Individual
Prefix:
First Name:SANFORD
Middle Name:ALLEN
Last Name:MULLEN
Suffix:JR
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 1:300 BUTLER ST
Mailing Address - Street 2:PALM BEACH PATHOLOGY PA
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-6006
Mailing Address - Country:US
Mailing Address - Phone:561-659-0770
Mailing Address - Fax:561-802-3504
Practice Address - Street 1:2013 PONCE DELEON AVE
Practice Address - Street 2:PALM BEACH PATHOLOGY PA
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-6019
Practice Address - Country:US
Practice Address - Phone:561-659-0770
Practice Address - Fax:561-802-3504
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36784207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043622400Medicaid
FL14123OtherBLUE CROSS BLUE SHIELD
220027875Medicare PIN
FL14123UMedicare PIN
FL14123YMedicare PIN
FL14123ZMedicare PIN
FL043622400Medicaid
FL14123OtherBLUE CROSS BLUE SHIELD