Provider Demographics
NPI:1730148099
Name:MULLINS, PENNY L (MD)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:L
Last Name:MULLINS
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 1:8153 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:OLD FORT
Mailing Address - State:OH
Mailing Address - Zip Code:44861
Mailing Address - Country:US
Mailing Address - Phone:419-992-4231
Mailing Address - Fax:419-992-4722
Practice Address - Street 1:8153 MAIN STREET
Practice Address - Street 2:
Practice Address - City:OLD FORT
Practice Address - State:OH
Practice Address - Zip Code:44861
Practice Address - Country:US
Practice Address - Phone:419-992-4231
Practice Address - Fax:419-992-4722
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHBM5446580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2034319Medicaid
OHH116410Medicare UPIN