Provider Demographics
NPI:1174505507
Name:MULDER, DAVID G (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:G
Last Name:MULDER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:5730 EXECUTIVE DR STE 230
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-1762
Mailing Address - Country:US
Mailing Address - Phone:978-536-7850
Mailing Address - Fax:978-536-7851
Practice Address - Street 1:100 BROOKSBY VILLAGE DRIVE
Practice Address - Street 2:BROOKSBY MEDICAL CLINIC
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960
Practice Address - Country:US
Practice Address - Phone:978-536-7850
Practice Address - Fax:877-280-9727
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3466207R00000X
MA231400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA31343OtherWELLMARK BCBS
IA0278101Medicaid
IAM20932Medicaid
1174505507OtherBCBS
04-40166OtherEVERCARE
522239464OtherTRICARE NORTH
IA31343OtherWELLMARK BCBS
17758Medicare ID - Type Unspecified
1174505507OtherBCBS
E30880Medicare UPIN