Provider Demographics
NPI:1932137908
Name:MULLOY, WAYNE GALE (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:GALE
Last Name:MULLOY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MRS
Other - First Name:LORETTA
Other - Middle Name:L
Other - Last Name:GANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:15035A EAST FRWY
Mailing Address - Street 2:
Mailing Address - City:CHANNELVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:77530
Mailing Address - Country:US
Mailing Address - Phone:281-452-5829
Mailing Address - Fax:281-457-6749
Practice Address - Street 1:15035A EAST FRWY
Practice Address - Street 2:
Practice Address - City:CHANNELVIEW
Practice Address - State:TX
Practice Address - Zip Code:77530
Practice Address - Country:US
Practice Address - Phone:281-452-5829
Practice Address - Fax:281-457-6749
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC7717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010011881OtherRAILROAD MEDICARE
TX009954Medicare ID - Type Unspecified
TXC19689Medicare UPIN
TX1932137908Medicare PIN