Provider Demographics
NPI:1275742173
Name:DANETTE R. ELLIOTT-MULLENS, DO, PA
Entity Type:Organization
Organization Name:DANETTE R. ELLIOTT-MULLENS, DO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANETTE
Authorized Official - Middle Name:RAI
Authorized Official - Last Name:ELLIOTT-MULLENS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:830-627-3385
Mailing Address - Street 1:2660 E. COMMON ST.
Mailing Address - Street 2:STE. #201
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-3168
Mailing Address - Country:US
Mailing Address - Phone:830-627-3385
Mailing Address - Fax:830-620-0294
Practice Address - Street 1:2660 E. COMMON ST.
Practice Address - Street 2:STE #201
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-3168
Practice Address - Country:US
Practice Address - Phone:830-627-3385
Practice Address - Fax:830-620-0294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 208000000X
TXK9775207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX006QFOtherBCBS GROUP PROV #
TX154062701Medicaid
TX154062701Medicaid
TX006QFOtherBCBS GROUP PROV #
TX00956TMedicare PIN