Provider Demographics
NPI:1013130426
Name:M.GAYLE MULLANAX, MD PA
Entity Type:Organization
Organization Name:M.GAYLE MULLANAX, MD PA
Other - Org Name:MULLANAX DERMATOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MILTON
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:MULLANAX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-261-1626
Mailing Address - Street 1:715 N FIELDER RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-4695
Mailing Address - Country:US
Mailing Address - Phone:817-261-1626
Mailing Address - Fax:817-275-0441
Practice Address - Street 1:715 N FIELDER RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4695
Practice Address - Country:US
Practice Address - Phone:817-261-1626
Practice Address - Fax:817-275-0441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD1750207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0007DQOtherBCBS OF TEXAS