Provider Demographics
NPI:1386647220
Name:MILLS, BRIAN GLENN SR (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:GLENN
Last Name:MILLS
Suffix:SR
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 1:975 SAINT JOHN PL
Mailing Address - Street 2:SUITE B
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4428
Mailing Address - Country:US
Mailing Address - Phone:951-658-2256
Mailing Address - Fax:951-658-8956
Practice Address - Street 1:975 SAINT JOHN PL
Practice Address - Street 2:STE B
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4428
Practice Address - Country:US
Practice Address - Phone:951-658-2256
Practice Address - Fax:951-658-8956
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4315213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE4315OtherLICENSE
P00101130OtherRAILROAD MEDICARE
CA000E43150Medicaid
CAU63121Medicare UPIN
CA000E43150Medicare PIN
CA000E43150Medicaid