Provider Demographics
NPI:1659471191
Name:MILLAR, MARYANN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYANN
Middle Name:
Last Name:MILLAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 THURBER BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:SMITHFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02917-1822
Mailing Address - Country:US
Mailing Address - Phone:781-933-9993
Mailing Address - Fax:781-933-5711
Practice Address - Street 1:300 TRADECENTER
Practice Address - Street 2:STE 4750
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-7420
Practice Address - Country:US
Practice Address - Phone:781-933-9993
Practice Address - Fax:781-933-5711
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA075885174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAF32849Medicare UPIN
MAJ12650Medicare ID - Type Unspecified