Provider Demographics
NPI:1225442247
Name:MCMULLEN, KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:MCMULLEN
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 1:801 YORK S T
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:206-639-0089
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:1821 SOUTH AVE W STE 402
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6518
Practice Address - Country:US
Practice Address - Phone:406-543-8512
Practice Address - Fax:406-541-8513
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA142278207N00000X
MA260111390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program