Provider Demographics
NPI:1659463339
Name:MULLALLY, WILLIAM J (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:MULLALLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-421-6540
Mailing Address - Fax:
Practice Address - Street 1:111 GROSSMAN DR
Practice Address - Street 2:NEUROLOGY
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4997
Practice Address - Country:US
Practice Address - Phone:781-849-2265
Practice Address - Fax:781-849-2274
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2011-06-07
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Provider Licenses
StateLicense IDTaxonomies
MA46261207R00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA111404OtherHARVARD PILGRIM
MA0014880OtherNEIGHBORHOOD HEALTH PLAN
MA3179591Medicaid
MA046261OtherTUFTS HEALTH PLAN
MAP00086706OtherMEDICARE RAILROAD
MAJ12153OtherBLUE CROSS
MA7011385-002OtherCIGNA
MA046261OtherTUFTS HEALTH PLAN
MA111404OtherHARVARD PILGRIM