Provider Demographics
NPI:1467557454
Name:MULLVAIN, JEFFREY A (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:MULLVAIN
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 1:4060 FOURTH AVE
Mailing Address - Street 2:#500
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2120
Mailing Address - Country:US
Mailing Address - Phone:619-260-1900
Mailing Address - Fax:619-260-1919
Practice Address - Street 1:4060 FOURTH AVENUE
Practice Address - Street 2:SUITE 500
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2120
Practice Address - Country:US
Practice Address - Phone:619-260-1900
Practice Address - Fax:619-260-1919
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57253207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G57253Medicaid
CA00G57253Medicaid