Provider Demographics
NPI:1164537304
Name:MULLEN, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
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 1:3100 MACCORKLE AVE SE
Mailing Address - Street 2:STE 203
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1228
Mailing Address - Country:US
Mailing Address - Phone:304-388-1724
Mailing Address - Fax:304-388-1721
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1227
Practice Address - Country:US
Practice Address - Phone:304-388-4170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2010207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1068868OtherWV DWC
WV001884657OtherWV BCBS
WV3810006147Medicaid
WV001884657OtherWV BCBS
WV3810006147Medicaid
WVP00339854Medicare PIN
WV4144694Medicare PIN
WV4144693Medicare PIN
WVP00398511Medicare PIN