Provider Demographics
NPI:1639361504
Name:DOCTOR CHARLES D MULLENIX MD SC
Entity Type:Organization
Organization Name:DOCTOR CHARLES D MULLENIX MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:MULLENIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-724-6617
Mailing Address - Street 1:1775 GLENVIEW RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-2975
Mailing Address - Country:US
Mailing Address - Phone:847-724-6617
Mailing Address - Fax:847-724-3123
Practice Address - Street 1:1775 GLENVIEW RD
Practice Address - Street 2:SUITE 114
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-2975
Practice Address - Country:US
Practice Address - Phone:847-724-6617
Practice Address - Fax:847-724-3123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4028871OtherAETNA
0538000001OtherDMERC
01605282OtherBLUE CROSS
01605282OtherBLUE CROSS
IL211384Medicare PIN
0538000001OtherDMERC