Provider Demographics
NPI:1386639615
Name:MCMULLEN, STACI PEREA (OD)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:PEREA
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6071 E WOODMEN RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-2607
Mailing Address - Country:US
Mailing Address - Phone:719-380-6808
Mailing Address - Fax:719-380-5656
Practice Address - Street 1:6071 E WOODMEN RD
Practice Address - Street 2:SUITE 205
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-2607
Practice Address - Country:US
Practice Address - Phone:719-380-6808
Practice Address - Fax:719-380-5656
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2151152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO88427811Medicaid
COU81576Medicare UPIN
COCF2073Medicare PIN