Provider Demographics
NPI:1760599187
Name:MULLEN, TIFFANY (DO)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MULLEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 W. GOOD HOPE ROAD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:325 E. SILVER SPRING DRIVE
Practice Address - Street 2:
Practice Address - City:WHITEFISH BAY
Practice Address - State:WI
Practice Address - Zip Code:53217-5222
Practice Address - Country:US
Practice Address - Phone:414-247-4800
Practice Address - Fax:414-247-4801
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00784994OtherRR MEDICARE
WIP00784994OtherRR MEDICARE
WI462364658Medicare PIN