Provider Demographics
NPI:1922204007
Name:TARA K. MULLEN, O.D., P.C.
Entity Type:Organization
Organization Name:TARA K. MULLEN, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:OPTOMETRIST
Authorized Official - Phone:423-442-8649
Mailing Address - Street 1:4525 HIGHWAY 411
Mailing Address - Street 2:SUITE B
Mailing Address - City:MADISONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37354-1536
Mailing Address - Country:US
Mailing Address - Phone:423-442-8649
Mailing Address - Fax:423-420-3441
Practice Address - Street 1:4525 HIGHWAY 411
Practice Address - Street 2:SUITE B
Practice Address - City:MADISONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37354-1536
Practice Address - Country:US
Practice Address - Phone:423-442-8649
Practice Address - Fax:423-420-3441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN2011152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3723784Medicare ID - Type Unspecified