Provider Demographics
NPI:1275847642
Name:MULLICAN, CHARLES N (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:N
Last Name:MULLICAN
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 1:711 N 36TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2977
Mailing Address - Country:US
Mailing Address - Phone:816-271-7190
Mailing Address - Fax:816-271-7672
Practice Address - Street 1:711 N 36TH ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2977
Practice Address - Country:US
Practice Address - Phone:816-271-7190
Practice Address - Fax:816-271-7672
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010020683207R00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1275847642Medicaid
MO080111091OtherRR MEDICARE
MO701000114Medicare PIN