Provider Demographics
NPI:1962422519
Name:MULLEN, STEPHEN ELI (OD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ELI
Last Name:MULLEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 MAPLE DR
Mailing Address - Street 2:PO BOX 1008
Mailing Address - City:PLATTE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64079-9640
Mailing Address - Country:US
Mailing Address - Phone:816-858-3954
Mailing Address - Fax:816-858-3954
Practice Address - Street 1:79 MAPLE DR
Practice Address - Street 2:
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-9640
Practice Address - Country:US
Practice Address - Phone:816-858-3954
Practice Address - Fax:816-858-3954
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004018249152W00000X
IL046009712152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO319083408Medicaid
ILP00245761Medicare ID - Type UnspecifiedRR MCR IND #
0480010002Medicare NSC
ILK14542Medicare ID - Type UnspecifiedIND #
MS256891639Medicare ID - Type UnspecifiedIND #
MOC40D609Medicare ID - Type UnspecifiedIND #
MO256891033Medicare ID - Type UnspecifiedIND #
MOP00240099Medicare ID - Type UnspecifiedRR MCR IND #
MO256891034Medicare ID - Type UnspecifiedIND #
MOC40D609BMedicare ID - Type UnspecifiedIND #
ILP00245759Medicare ID - Type UnspecifiedRR MCR IND #
V01591Medicare UPIN
MOP00245762Medicare ID - Type UnspecifiedRR MCR IND #
MO319083408Medicaid
ILK14526Medicare ID - Type UnspecifiedIND #