Provider Demographics
NPI:1174501332
Name:MULLIN, RANDALL L (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:MULLIN
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 1:110 S DEPOT ST
Mailing Address - Street 2:
Mailing Address - City:ANNAWAN
Mailing Address - State:IL
Mailing Address - Zip Code:61234-7768
Mailing Address - Country:US
Mailing Address - Phone:309-944-5124
Mailing Address - Fax:309-721-1407
Practice Address - Street 1:110 S DEPOT ST
Practice Address - Street 2:
Practice Address - City:ANNAWAN
Practice Address - State:IL
Practice Address - Zip Code:61234-7768
Practice Address - Country:US
Practice Address - Phone:309-944-5124
Practice Address - Fax:309-721-1407
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1174501332Medicaid
IL036048491Medicaid
IL0360484912Medicaid
IL036048491Medicaid
IL0360484912Medicaid