Provider Demographics
NPI:1558365205
Name:MULLINS, BRENT A (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:A
Last Name:MULLINS
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 1:281 BELLE MEADE LN
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-3028
Mailing Address - Country:US
Mailing Address - Phone:901-734-0240
Mailing Address - Fax:
Practice Address - Street 1:281 BELLE MEADE LN
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-3028
Practice Address - Country:US
Practice Address - Phone:901-734-0240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18565207RH0003X
TN18880207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS115373Medicaid
TN3835436Medicaid
TN3835436Medicare PIN
A99815Medicare UPIN
MS115373Medicaid