Provider Demographics
NPI:1558307280
Name:MULLINS, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MULLINS
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 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-955-6522
Mailing Address - Fax:208-955-6503
Practice Address - Street 1:1115 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5738
Practice Address - Country:US
Practice Address - Phone:208-498-1080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5653207P00000X
IDM-5653207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003816800Medicaid
ID003816800Medicaid
ID1123136Medicare ID - Type Unspecified