Provider Demographics
NPI:1396856019
Name:MULLAN, JOAN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:C
Last Name:MULLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:MULLAN
Other - Last Name:GOLDWATER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:211 E CHICAGO AVE
Mailing Address - Street 2:SUITE 1050
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2637
Mailing Address - Country:US
Mailing Address - Phone:312-944-6677
Mailing Address - Fax:312-944-3346
Practice Address - Street 1:211 E CHICAGO AVE
Practice Address - Street 2:SUITE 1050
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2637
Practice Address - Country:US
Practice Address - Phone:312-944-6677
Practice Address - Fax:312-944-3346
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087186207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087186Medicaid
ILF79221Medicare UPIN
IL036087186Medicaid