Provider Demographics
NPI:1205908134
Name:MULLEN, CHARLES J (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:MULLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:35 MILES ST
Practice Address - Street 2:
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-4047
Practice Address - Country:US
Practice Address - Phone:207-563-4342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME149322085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0007119052OtherAETNA
ME025381OtherANTHEM
MEMM7411Medicare ID - Type Unspecified
NH30011634Medicaid
NH01Y003974NH01OtherANTHEM
ME2315673OtherAETNA USHC
NHRE7147Medicare ID - Type Unspecified
ME300088418Medicare ID - Type UnspecifiedRAILROAD
MEM140318OtherCIGNA
MEG16597Medicare UPIN
MM741101Medicare PIN
MEG16597OtherHPHC
ME275880099Medicaid