Provider Demographics
NPI:1740203389
Name:MCMULLEN, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MCMULLEN
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:PO BOX 2030
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34447-2030
Mailing Address - Country:US
Mailing Address - Phone:352-621-3100
Mailing Address - Fax:352-621-3121
Practice Address - Street 1:6201 N SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34428-6712
Practice Address - Country:US
Practice Address - Phone:352-621-3100
Practice Address - Fax:352-621-3121
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49726207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378304900Medicaid
FL27507OtherBLUE CROSS BLUE SHIELD
FLF40076Medicare UPIN
220015893Medicare PIN
FL27507YMedicare PIN
FL27507ZMedicare PIN