Provider Demographics
NPI:1609695238
Name:MULU, BERNARD
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:
Last Name:MULU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9333 STEEPLE CT
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-5820
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9333 STEEPLE CT
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-5820
Practice Address - Country:US
Practice Address - Phone:262-753-3116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIM4540808900206OtherDRIVING LICENSE