Provider Demographics
NPI:1144364043
Name:MULLINS, KENDALL CLARK (OD)
Entity type:Individual
Prefix:DR
First Name:KENDALL
Middle Name:CLARK
Last Name:MULLINS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 COUNTY ROAD 941
Mailing Address - Street 2:
Mailing Address - City:CLANTON
Mailing Address - State:AL
Mailing Address - Zip Code:35045-7979
Mailing Address - Country:US
Mailing Address - Phone:205-585-6461
Mailing Address - Fax:
Practice Address - Street 1:9220 MARNE RD
Practice Address - Street 2:
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905-5515
Practice Address - Country:US
Practice Address - Phone:706-682-3938
Practice Address - Fax:706-682-3931
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-779-TA-718152W00000X
GAOPT001400152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102I419028Medicare PIN
GA41ZCCMNMedicare ID - Type Unspecified
GAU49833Medicare UPIN