Provider Demographics
NPI:1417964990
Name:MILLAR, MARYANN ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYANN
Middle Name:ELIZABETH
Last Name:MILLAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 MEDICAL CENTER DR
Mailing Address - Street 2:POD A
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-6600
Mailing Address - Country:US
Mailing Address - Phone:315-329-4968
Mailing Address - Fax:315-329-4964
Practice Address - Street 1:4117 MEDICAL CENTER DR
Practice Address - Street 2:POD A
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6600
Practice Address - Country:US
Practice Address - Phone:315-329-4968
Practice Address - Fax:315-329-4864
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192084-1207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01463083Medicaid
NYJ400032183Medicare PIN
NYF69643Medicare UPIN
NY01463083Medicaid