Provider Demographics
NPI:1407871296
Name:MULQUEENY, SEAN P (OD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:P
Last Name:MULQUEENY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 N NEW BALLAS RD
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6714
Mailing Address - Country:US
Mailing Address - Phone:314-542-3600
Mailing Address - Fax:314-542-4041
Practice Address - Street 1:612 N NEW BALLAS ROAD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6714
Practice Address - Country:US
Practice Address - Phone:314-542-3600
Practice Address - Fax:314-542-4041
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03017152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U51579Medicare UPIN