Provider Demographics
NPI:1295345056
Name:MCMULLAN, DELAND MAURICE JR
Entity type:Individual
Prefix:
First Name:DELAND
Middle Name:MAURICE
Last Name:MCMULLAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 970646
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-0088
Mailing Address - Country:US
Mailing Address - Phone:734-320-4819
Mailing Address - Fax:
Practice Address - Street 1:1122 WALNUT ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-3937
Practice Address - Country:US
Practice Address - Phone:734-320-4819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
MI12585922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer