Provider Demographics
NPI:1215966759
Name:MULLINS, MARK M (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:MULLINS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 NE 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741
Mailing Address - Country:US
Mailing Address - Phone:541-475-6171
Mailing Address - Fax:541-475-6172
Practice Address - Street 1:28 NE 12TH ST
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741
Practice Address - Country:US
Practice Address - Phone:541-475-6171
Practice Address - Fax:541-475-6172
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR271654111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269480Medicaid
OR269480Medicaid
T67940Medicare UPIN