Provider Demographics
NPI:1023108560
Name:MULLEN, TARA K (OD)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:K
Last Name:MULLEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2011152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3943429Medicare ID - Type Unspecified
TNU79262Medicare UPIN