Provider Demographics
NPI:1356402739
Name:MCMULLEN, JULIE L (OD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:L
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:L
Other - Last Name:MALMGREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1052 GULL RD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1734
Mailing Address - Country:US
Mailing Address - Phone:269-343-1684
Mailing Address - Fax:269-343-5375
Practice Address - Street 1:1052 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1734
Practice Address - Country:US
Practice Address - Phone:269-343-1684
Practice Address - Fax:269-343-5375
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003710152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900C913660OtherBCBSM
MIN26930163Medicare PIN
MI900C913660OtherBCBSM
MI0N91680004Medicare PIN