Provider Demographics
NPI:1447271986
Name:ELLIOTT-MULLENS, ROD LEE (DO)
Entity type:Individual
Prefix:
First Name:ROD
Middle Name:LEE
Last Name:ELLIOTT-MULLENS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 MASON RIDGE CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8512
Mailing Address - Country:US
Mailing Address - Phone:314-996-8072
Mailing Address - Fax:314-996-8072
Practice Address - Street 1:969 N MASON RD STE 250
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6370
Practice Address - Country:US
Practice Address - Phone:314-273-0195
Practice Address - Fax:314-273-0190
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024006433207RS0012X
ORDO150936207RP1001X, 207RS0012X
TXK9776207RP1001X
TXK-9776207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500621775Medicaid
ORR186837OtherMEDICARE
TX037600601Medicaid
OR10725082OtherCAQH ID
OR500621775Medicaid
TX037600601Medicaid