Provider Demographics
NPI:1306822259
Name:MILLARD, JACK RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:RICHARD
Last Name:MILLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:25 ROCKY POND RD
Mailing Address - Street 2:
Mailing Address - City:BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01505-1511
Mailing Address - Country:US
Mailing Address - Phone:860-963-6356
Mailing Address - Fax:
Practice Address - Street 1:320 POMFRET ST
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1836
Practice Address - Country:US
Practice Address - Phone:860-963-6356
Practice Address - Fax:860-963-6335
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT151562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B97184Medicare UPIN