Provider Demographics
NPI:1447236013
Name:MCMULLEN, TIMOTHY R (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:MCMULLEN
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 1:6488 E MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-7310
Mailing Address - Country:US
Mailing Address - Phone:614-552-2300
Mailing Address - Fax:614-552-2305
Practice Address - Street 1:6488 E MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-7310
Practice Address - Country:US
Practice Address - Phone:614-552-2300
Practice Address - Fax:614-552-2305
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-6952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0757471Medicaid
OHE70301Medicare UPIN
OH0757471Medicaid