Provider Demographics
NPI:1063405025
Name:MULVANEY, MICHAEL J (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:MULVANEY
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 1:264 WASHINGTON AVENUE EXT STE 201
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-6352
Mailing Address - Country:US
Mailing Address - Phone:518-452-1928
Mailing Address - Fax:518-362-1348
Practice Address - Street 1:264 WASHINGTON AVENUE EXT STE 201
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203
Practice Address - Country:US
Practice Address - Phone:518-452-1928
Practice Address - Fax:518-362-1348
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY182393207ND0101X
NY182393-1207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1823931OtherNYLICENSE
NYRA1608Medicare PIN
NYE88296Medicare UPIN