Provider Demographics
NPI:1861493603
Name:MULLINS, ANDREW DARYL (DO)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:DARYL
Last Name:MULLINS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 W NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3112
Mailing Address - Country:US
Mailing Address - Phone:309-680-5000
Mailing Address - Fax:309-680-1002
Practice Address - Street 1:2420 W NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-3112
Practice Address - Country:US
Practice Address - Phone:309-680-5000
Practice Address - Fax:309-680-1002
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0188822085R0204X, 2085R0204X
IL0361653922085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001300048Medicaid
MD22152300Medicaid