Provider Demographics
NPI:1679581870
Name:MULLEN, MARK JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAY
Last Name:MULLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:JAY
Other - Last Name:MULLEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1648 HUNTINGDON PIKE
Mailing Address - Street 2:MEDICAL STAFF OFFICE 1ST FLR
Mailing Address - City:MEADOWBROOK
Mailing Address - State:PA
Mailing Address - Zip Code:19046-8001
Mailing Address - Country:US
Mailing Address - Phone:215-938-3450
Mailing Address - Fax:215-938-3829
Practice Address - Street 1:23 BUSTLETON PIKE
Practice Address - Street 2:SUITE 200
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-6446
Practice Address - Country:US
Practice Address - Phone:215-464-0770
Practice Address - Fax:267-579-0720
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD0402071E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F00911Medicare UPIN
PA608445Medicare PIN