Provider Demographics
NPI:1245613082
Name:MILLETTE, THEODORE II (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:MILLETTE
Suffix:II
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 1:1300 JEFFERSON PARK AVE.
Mailing Address - Street 2:PO BOX 800386
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-3363
Mailing Address - Country:US
Mailing Address - Phone:434-924-9119
Mailing Address - Fax:
Practice Address - Street 1:1204 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-2824
Practice Address - Country:US
Practice Address - Phone:434-924-5321
Practice Address - Fax:434-244-4412
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-3719208000000X
VA0101272247208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics