Provider Demographics
NPI:1528387131
Name:MULLVAIN, JACQUELINE A (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:MULLVAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:ANN
Other - Last Name:ZIEHR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1211 FISH HATCHERY RD.
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1909
Mailing Address - Country:US
Mailing Address - Phone:608-252-8000
Mailing Address - Fax:608-410-2905
Practice Address - Street 1:1211 FISH HATCHERY RD.
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1909
Practice Address - Country:US
Practice Address - Phone:608-252-8000
Practice Address - Fax:608-410-2905
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60345-20207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1528387131Medicaid
WIK400319156Medicare PIN