Provider Demographics
NPI:1285666222
Name:HENNESSEE, MILLARD THOMAS (DPM)
Entity Type:Individual
Prefix:DR
First Name:MILLARD
Middle Name:THOMAS
Last Name:HENNESSEE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-1502
Mailing Address - Country:US
Mailing Address - Phone:617-268-1745
Mailing Address - Fax:617-268-1748
Practice Address - Street 1:654 E BROADWAY
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-1502
Practice Address - Country:US
Practice Address - Phone:617-268-1745
Practice Address - Fax:617-268-1748
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA001614213E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY70691OtherBLUE SHIELD
MA0341487Medicaid
MA0341487Medicaid
MAY70691Medicare ID - Type Unspecified
MAT58723Medicare UPIN