Provider Demographics
NPI:1922065721
Name:MULLEN, KENNETH H (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:H
Last Name:MULLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 241011
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95241-9511
Mailing Address - Country:US
Mailing Address - Phone:209-339-7435
Mailing Address - Fax:209-339-7858
Practice Address - Street 1:1901 W KETTLEMAN LN
Practice Address - Street 2:# 200
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4337
Practice Address - Country:US
Practice Address - Phone:209-334-8540
Practice Address - Fax:209-368-2885
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27186207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA43262Medicare UPIN
CA00G271862Medicare ID - Type UnspecifiedMEDICARE NUMBER