Provider Demographics
NPI:1104829464
Name:MILLS, JERRAD SCOTT (OD)
Entity Type:Individual
Prefix:
First Name:JERRAD
Middle Name:SCOTT
Last Name:MILLS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:TX
Mailing Address - Zip Code:77536-4161
Mailing Address - Country:US
Mailing Address - Phone:281-479-4570
Mailing Address - Fax:281-479-7895
Practice Address - Street 1:2009 CENTER ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:TX
Practice Address - Zip Code:77536-4161
Practice Address - Country:US
Practice Address - Phone:281-479-4570
Practice Address - Fax:281-479-7895
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6368TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0042PPOtherBLUE CROSS BLUE SHIELD
TX81990QOtherBLUE CROSS BLUE SHIELD
TX81990QOtherBLUE CROSS BLUE SHIELD
TX0042PPOtherBLUE CROSS BLUE SHIELD
TX6014880001Medicare NSC