Provider Demographics
NPI:1154862217
Name:MULLICK DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:MULLICK DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUPARNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-572-0005
Mailing Address - Street 1:PO BOX 758
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242-0758
Mailing Address - Country:US
Mailing Address - Phone:901-572-0005
Mailing Address - Fax:
Practice Address - Street 1:3036 CENTRE OAK WAY
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-6302
Practice Address - Country:US
Practice Address - Phone:901-572-0005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD49897207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty