Provider Demographics
NPI:1699758136
Name:MCMULLEN, SUSAN C (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:C
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 S BECKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1906
Mailing Address - Country:US
Mailing Address - Phone:903-596-3588
Mailing Address - Fax:
Practice Address - Street 1:100 MUNICIPAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-3702
Practice Address - Country:US
Practice Address - Phone:903-713-1571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25065207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ102533Medicaid
AZ200017697OtherRR MEDICARE
AZ86080015085308A020OtherTRIWEST
AZ86080015085259B098OtherTRICARE
AZ86080015085259B098OtherTRICARE
AZ200017697OtherRR MEDICARE
AZZ72989Medicare PIN
AZ102533Medicaid