Provider Demographics
NPI:1316051006
Name:MULLIN, DOUGLAS WAYNE (CO)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:MULLIN
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 AMELIA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5772
Mailing Address - Country:US
Mailing Address - Phone:765-404-7285
Mailing Address - Fax:
Practice Address - Street 1:3802 AMELIA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5772
Practice Address - Country:US
Practice Address - Phone:765-404-7285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN150971744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4148480002Medicare PIN