Provider Demographics
NPI:1265437362
Name:MULA, GREGORY MARK (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MARK
Last Name:MULA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GREGORY
Other - Middle Name:MARK
Other - Last Name:MULA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:16061 DOCTORS BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-1479
Mailing Address - Country:US
Mailing Address - Phone:985-542-1334
Mailing Address - Fax:985-318-1005
Practice Address - Street 1:16061 DOCTORS BLVD
Practice Address - Street 2:STE B
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1479
Practice Address - Country:US
Practice Address - Phone:985-542-1334
Practice Address - Fax:985-318-1005
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018272174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1377830Medicaid
LA1377830Medicaid
LAE01729Medicare UPIN