Provider Demographics
NPI:1174524250
Name:MULLICK, MRINAL (MD)
Entity type:Individual
Prefix:
First Name:MRINAL
Middle Name:
Last Name:MULLICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:350 PARK ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1784
Mailing Address - Country:US
Mailing Address - Phone:270-843-5103
Mailing Address - Fax:270-843-5104
Practice Address - Street 1:350 PARK ST
Practice Address - Street 2:SUITE 204
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1784
Practice Address - Country:US
Practice Address - Phone:270-843-5103
Practice Address - Fax:270-843-5104
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY354172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64011802Medicaid
0605103Medicare PIN
KYH15502Medicare UPIN