1063406478 NPI number — WILLIAM L MULLIGAN PHD

Table of content: WILLIAM L MULLIGAN PHD (NPI 1063406478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063406478 NPI number — WILLIAM L MULLIGAN PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULLIGAN
Provider First Name:
WILLIAM
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063406478
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4085
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23454-0085
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-410-0700
Provider Business Mailing Address Fax Number:
757-222-3384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1403 GREENBRIER PKWY
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23320-0614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-410-0700
Provider Business Practice Location Address Fax Number:
757-222-3384
Provider Enumeration Date:
08/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  0810000729 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 172017, 267207 . This is a "ANTHEM, BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2149701 . This is a "UBH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 54-1088477 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 54-1088477 . This is a "VIRGINIA HEALTH NETWORK" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 54-1088477 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 031538 . This is a "VALUE OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 089211, 37077 . This is a "OPTIMAHEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 11240084 . This is a "CAQH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2166701 . This is a "CBH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com