Provider Demographics
NPI:1619073749
Name:MULLEN, JERRY LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:MULLEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 NW EXPRESSWAY
Mailing Address - Street 2:STE 130
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-1584
Mailing Address - Country:US
Mailing Address - Phone:405-721-7450
Mailing Address - Fax:405-721-7491
Practice Address - Street 1:7101 NW EXPRESSWAY
Practice Address - Street 2:#130
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-1584
Practice Address - Country:US
Practice Address - Phone:405-721-7450
Practice Address - Fax:405-721-7491
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK963152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200083220BMedicaid
OK200083220AMedicaid
OKP00068003OtherMEDICARE RAILROAD
OK800522248Medicare PIN
OKT40582Medicare UPIN
OK5257470001Medicare NSC