Provider Demographics
NPI:1215049788
Name:MCMULLIN, CHARLES J JR (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:MCMULLIN
Suffix:JR
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 1:300 FOXHEAD SHORES DR
Mailing Address - Street 2:
Mailing Address - City:LINN CREEK
Mailing Address - State:MO
Mailing Address - Zip Code:65052-2563
Mailing Address - Country:US
Mailing Address - Phone:573-480-4721
Mailing Address - Fax:
Practice Address - Street 1:300 FOXHEAD SHORES DR
Practice Address - Street 2:
Practice Address - City:LINN CREEK
Practice Address - State:MO
Practice Address - Zip Code:65052-2563
Practice Address - Country:US
Practice Address - Phone:573-480-4721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD117270174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205428204Medicaid
MOF79542Medicare UPIN
MO205428204Medicaid