Provider Demographics
NPI:1952367310
Name:MULLINS, KEITH MARTIN (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:MARTIN
Last Name:MULLINS
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 1:2699 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2710
Mailing Address - Country:US
Mailing Address - Phone:562-426-3333
Mailing Address - Fax:
Practice Address - Street 1:2699 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2710
Practice Address - Country:US
Practice Address - Phone:562-426-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70634174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA208M00000XMedicare UPIN