Provider Demographics
NPI:1174520837
Name:MULLEN, THOMAS N (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:N
Last Name:MULLEN
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 1:738 DEODARA DR
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-2310
Mailing Address - Country:US
Mailing Address - Phone:626-676-3797
Mailing Address - Fax:
Practice Address - Street 1:126 SEQUOYAH TRL
Practice Address - Street 2:
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736-4360
Practice Address - Country:US
Practice Address - Phone:706-965-2179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000645169CMedicaid
GA000645169CMedicaid
GA08BDNPCMedicare ID - Type Unspecified