Provider Demographics
NPI:1174519607
Name:MULLY, THADDEUS (MD)
Entity type:Individual
Prefix:
First Name:THADDEUS
Middle Name:
Last Name:MULLY
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 1:640 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4853
Mailing Address - Country:US
Mailing Address - Phone:617-252-6880
Mailing Address - Fax:
Practice Address - Street 1:400 PARNASSUS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2202
Practice Address - Country:US
Practice Address - Phone:415-476-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221206207ND0900X, 207ZD0900X
CAA65484207ZP0102X, 207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH37838Medicare UPIN
NY0J1481Medicare ID - Type Unspecified