Provider Demographics
NPI:1285841601
Name:JERRY L. MULLEN, O.D., P.C.
Entity Type:Organization
Organization Name:JERRY L. MULLEN, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-721-7450
Mailing Address - Street 1:7101 NW EXPRESSWAY
Mailing Address - Street 2:#130
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-1584
Mailing Address - Country:US
Mailing Address - Phone:405-721-7450
Mailing Address - Fax:405-721-7491
Practice Address - Street 1:7101 NW EXPRESSWAY
Practice Address - Street 2:#130
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-1584
Practice Address - Country:US
Practice Address - Phone:405-721-7450
Practice Address - Fax:405-721-7491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK963152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200083220AMedicaid
OKP00068003OtherMEDICARE RAILROAD
OK200083220BMedicaid
OK5257470001Medicare NSC
OKT40582Medicare UPIN
OK800522248Medicare PIN