Provider Demographics
NPI:1497904387
Name:MULLEN, DOUGLAS A (US NAVY IDC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:MULLEN
Suffix:
Gender:M
Credentials:US NAVY IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS IWO JIMA (LHD7)
Mailing Address - Street 2:MEDICAL DEPARTMENT
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09574-1664
Mailing Address - Country:US
Mailing Address - Phone:757-443-8007
Mailing Address - Fax:
Practice Address - Street 1:USS IWO JIMA (LHD7)
Practice Address - Street 2:MEDICAL DEPARTMENT
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09574-1664
Practice Address - Country:US
Practice Address - Phone:757-443-8007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman