Provider Demographics
NPI:1700190642
Name:JEFFRY A MULLVAIN MD INC
Entity Type:Organization
Organization Name:JEFFRY A MULLVAIN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MULLVAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-260-1900
Mailing Address - Street 1:4060 FOURTH AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-260-1900
Mailing Address - Fax:619-260-1900
Practice Address - Street 1:4060 FOURTH AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-260-1900
Practice Address - Fax:619-260-1919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57253207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG572530Medicaid
CAG572530Medicaid
CAW18786Medicare PIN