Provider Demographics
NPI:1700916475
Name:MULLIN, BRYAN R (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:R
Last Name:MULLIN
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 1:3900 CONNECTICUT AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008
Mailing Address - Country:US
Mailing Address - Phone:202-686-4455
Mailing Address - Fax:
Practice Address - Street 1:2204 WILBORN AVE
Practice Address - Street 2:HALIFAX REGIONAL MEDICAL CENTER
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592
Practice Address - Country:US
Practice Address - Phone:434-517-3229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101053735207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F18094Medicare UPIN