Provider Demographics
NPI:1093797045
Name:MCMULLEN, KEVIN PATRICK (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
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 1828
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1828
Mailing Address - Country:US
Mailing Address - Phone:704-878-4615
Mailing Address - Fax:704-878-7193
Practice Address - Street 1:557 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4107
Practice Address - Country:US
Practice Address - Phone:704-878-4615
Practice Address - Fax:704-878-7193
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC99009412085R0001X
IN01070320A2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2004948000Medicaid
IN201037980Medicaid
INP01420734OtherRAILROAD MEDICARE
7957688OtherAETNA
NC802872OtherPARTNERS
SCQ0094CMedicaid
VA10001251Medicaid
NC1333UOtherBCBS
NC891333UMedicaid
IN000000746372OtherANTHEM
IN000000990588OtherANTHEM PIN
NCC6010OtherMEDCOST
INP01420734OtherRAILROAD MEDICARE
7957688OtherAETNA
NC1333UOtherBCBS
IN201037980Medicaid
WV2004948000Medicaid
INM400057338Medicare PIN