Provider Demographics
NPI:1104974641
Name:MULL, DAVID H (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:H
Last Name:MULL
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 1:2751 ALBERT L. BICKNELL DRIVE
Mailing Address - Street 2:SUITE 5C
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3920
Mailing Address - Country:US
Mailing Address - Phone:318-227-9777
Mailing Address - Fax:318-459-1188
Practice Address - Street 1:2751 ALBERT L. BICKNELL DRIVE
Practice Address - Street 2:SUITE 5C
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3920
Practice Address - Country:US
Practice Address - Phone:318-227-9777
Practice Address - Fax:318-459-1188
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19445174400000X
LA017580208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1810010OtherUHC
AL000039815Medicaid
AL51039815OtherBCBS OF AL
AL5536685OtherAETNA PROVIDER #
MS0119079Medicaid
ALB65309OtherHEALTHSPRINGS OF AL
ALB65309OtherHEALTHSPRINGS OF AL
AL000039815Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
MS0119079Medicaid