Provider Demographics
NPI:1942423728
Name:MULCAHY, BRIAN J (CERTIFIED PEDORTHIST)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:J
Last Name:MULCAHY
Suffix:
Gender:M
Credentials:CERTIFIED PEDORTHIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 BELLEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-1307
Mailing Address - Country:US
Mailing Address - Phone:973-450-3077
Mailing Address - Fax:973-450-3077
Practice Address - Street 1:573 BELLEVILLE AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-1307
Practice Address - Country:US
Practice Address - Phone:973-450-3077
Practice Address - Fax:973-450-3077
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN964225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8502501Medicaid
NJ3875790001Medicare ID - Type Unspecified